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Internal Medicine > OHCEPS - The Nervous System > Flashcards

OHCEPS - The Nervous System Flashcards

1
Q

Dizziness - Clarify what?

A
  1. Sense of rotation = vertigo.
  2. Swimminess or lightheadedness –> rather non specific symptom which can be related to pathology in many different systems.
  3. Pre-syncope –> rather unique feeling one gets just prior to fainting.
  4. Incoordination –> many will say they are dizzy when, in fact, they can’t walk straight due to either ataxia or weakness.
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2
Q

Headache?

A

Treat as any other pain + Ask about facial or visual symptoms.

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3
Q

Numbness and weakness?

A
  1. These two words are often confused by patients - Describing a leg as numb when it is weak with normal sensation.
  2. Also, patients may report “numbness” when, in fact, they are experiencing pins-and-needles or pain.
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4
Q

Tremor - Ask what?

A
  1. Here you should establish if the tremor occurs only at rest, only when attempting an action or both.
  2. Worse any particular time of the day.
  3. Severity can be established in terms of its functional consequence (can’t hold a cup/put food to mouth?).
  4. Again, establish EXACTLY what is being described. A tremor is a shaking, regular or jerky involuntary movement.
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5
Q

Falls and loss of consciousness (LOC) - Ask what?

A
  1. Eyewitness is vital.
  2. Establish also whether the patient actually lost consciousness or not.
  3. People often describe “blacking out” when in fact they simply fell to the ground –> Drop attacks have no LOC.
  4. Important question –> Can you remember hitting the ground?
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6
Q

Falls and LOC - Preceding symptoms?

A

They may point towards a different organ system:

  1. Sweating + Weakness could be a marker of hypoglycemia.
  2. Palpitations may indicate a cardiac dysrhythmia.
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7
Q

Seizures - Ask what?

A
  1. Impairment of consciousness + seek collateral histories.
  2. Lay persons usually consider seizure = fit = tonic clonic seizure.
  3. A surprising number of people also suffer “pseudoseizures” which are non-organic and have a psychological cause.
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8
Q

Seizures - History-taking - Few points to consider:

A
  1. Syncopal attacks can often cause a few tonic-clonic jerks which may be mistaken for epilepsy.
  2. True tonic-clonic seizures may cause tongue-biting, urinary and fecal incontinence, or ALL of the above.
  3. People presenting with pseudoseizure can have true epilepsy as well and vice versa.
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9
Q

Visual symptoms?

A
  1. Commonly visual loss, double-vision, or photophobia.
  2. Establish EXACTLY what is being experienced –> Diplopia is often complained of when, in fact, the vision is blurred or sight is generally poor (amblyopia) or clouded.
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10
Q

Rest of history - Remember to ask?

A

If the patient is right or left-handed –> consider disability from loss of function and may also be useful when thinking about cerebral lesions.

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11
Q

Rest of history - Direct questioning?

A

Enquire neurological symptoms OTHER than the presenting complaint:

  1. Headaches
  2. Fits
  3. Faints
  4. “Funny turns”
  5. Blackouts
  6. Visual symptoms
  7. Pins-and-needles
  8. Tingling
  9. Numbness
  10. Weakness
  11. Incontinence
  12. Constipation
  13. Urinary retention
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12
Q

PMH - Ask?

A

A birth history is important –> Particularly in epilepsy –> Brain injury at birth has neurological consequences.

  1. HTN - if so, what treatment?
  2. DM - type, treatment?
  3. Thyroid disease
  4. Mental illness (eg depression)
  5. Meningitis or encephalitis
  6. Head or spinal-injuries
  7. Epilepsy, convulsions, or seizures
  8. Cancers
  9. HIV/AIDS
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13
Q

DHx - Ask?

A
  1. Anticonvulsant therapy - current, previous.
  2. OCPs
  3. Steroids
  4. Anticoagulants or anti-platelet agents.
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14
Q

FHx - Ask?

A

Thoroughly –> Ask about neurological diagnoses and evidence of missed diagnoses (eg seizures, blackouts).

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15
Q

SHx - Ask?

A
  1. Occupation + Exposure to heavy metals or other neurotoxins.
  2. Driving? - Many neurological conditions have implications here.
  3. Ask about the home environment thoroughly - very useful when considering handicaps and consequences of the diagnosis.
  4. Ask about support systems - family, friends, home-helps, day centre visits etc.
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16
Q

Brief outline of neurological exam?

A
  1. Inspection, mood, conscious level.
  2. Speech and higher mental functions.
  3. Cranial nerves II-XII
  4. Motor system
  5. Sensation
  6. Co-ordination
  7. Gait
  8. Any extra tests
  9. Other relevant exams –> skull, spine, neck stiffness, ear drums, BP, anterior chest, carotid arteries, breasts, abdomen, lymph nodes.
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17
Q

General inspection and mental state?

A
  1. Are they accompanied by carers - how do they interact with those people.
  2. Do they use any walking aids?
  3. Any abnormal movements?
  4. Observe gait as they approach the clinic room.
  5. Any speech disturbance
  6. What is their mood like?
  7. Ask how they feel.
  8. State of clothing, hair, skin, nails?
  9. Restlessness, inappropriately high spirits, pressure of speech?
  10. Obviously depressed with disinterest?
  11. Denying any disability?
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18
Q

Speech and language - Exam?

A
  1. May be evident from the start - no formal testing required.
  2. Briefly test their language function by asking them to read or obey a simple written command (eg close your eyes) + write a short sentence.
  3. If apparently problematic, speech can be tested formally by asking the patient to respond to progressively harder questions… yes/no, simple statements, more complicated statements and finally tongue twisters.
  4. Before everything –> Ensure that the patient is NOT DEAF + They can usually understand English.
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19
Q

Dysarthria is?

A

A defect of articulation –> Language function is INTACT (writing will be unaffected).

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20
Q

Dysarthria - Lesion may be?

A
  1. Cerebellar lesion
  2. LMN lesion of the cranial nerves
  3. Extrapyramidal lesion
  4. Problem with muscles in the mouth and jaws or their nerve supply.
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21
Q

Dysarthria - Exam?

A
  1. Listen for slurring and the rhythm of speech.
  2. Test function of different structures by asking the patient to repeat “Yellow Lorry” or words with D, L, T –> Tongue function.
  3. Lip function –> Peter Piper picked a pickle.
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22
Q

Dysarthria - cerebellar lesions?

A

Slow, slurred, low volume with equal emphasis on all syllables (“scanning”).

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23
Q

Dysarthria - Facial weakness?

A

Speech is slurred.

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24
Q

Dysarthria - extrapyramidal lesions?

A
  1. Monotonous
  2. Low volume
  3. Lacking in normal rhythm
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25
Q

Dysphonia is?

A

Defective volume - huskiness,

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26
Q

Dysphonia - etiology?

A
  1. Laryngeal disease
  2. Laryngeal nerve palsy
  3. Rarely muscular disease such as myasthenia gravis.
  4. May also be psychological.
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27
Q

Dysphasia is?

A

Defect of language, NOT JUST SPEECH, so reading and writing may also be affected - some patients attempt to overcome speaking difficulties with a notepad and a pen only to be bitterly disappointed.

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28
Q

Global dysphasia?

A

Patient is unable to speak or understand speech at all.

Broca and Wernicke affected.

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29
Q

Expressive dysphasia?

A
  1. Lesion in Broca (frontal lobe) - involved in language production.
  2. Understanding remains intact.
  3. Unable to answer questions appropriately.
  4. Speech is non-fluent, broken with abnormal word ordering.
  5. Unable to repeat sentences.
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30
Q

Expressive dysphasia - other terms?

A

Anterior, motor, or Broca’s dysphasia.

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31
Q

Receptive dysphasia?

A
  1. Lesion in Wernicke - Problems understanding spoken or written language (dyslexia) and problems with word-finding.
  2. Unable to understand commands or questions.
  3. Speech is fluent with lots of meaningless grammatical elements.
  4. May contain meaningless words.
  5. Unable to repeat sentences.
  6. Patients are often unaware of their speech difficulty and will talk nonsense contentedly –> although may become frustrated with other people’s lack of understanding!!!
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32
Q

Other terms for receptive dysphasia?

A

Posterior, sensory, or Wernicke’s dysphasia.

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33
Q

Jargon dysphasia?

A

Describes a severe form of receptive dysphasia containing only meaningless words (neologisms) and sounds.

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34
Q

Paraphasia is?

A

The supplementation of one word with another.

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35
Q

Conductive dysphasia?

A
  1. Lesions in the arcuate fasciculus and/or other connections between the 2 primary language areas.
  2. Patient can comprehend and respond appropriately.
  3. Unable to REPEAT A SENTENCE.
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36
Q

Nominal dysphasia?

A
  1. All language function is intact EXCEPT for naming of objects.
  2. Caused by lesion in angular gyrus.
  3. Patient may function with “circumlocution” –> eg says “that thing that I write with” if unable to say “pen”.
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37
Q

Cognitive function - How to exam?

A

With the abbreviated mental test score (10 points).

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38
Q

What does the abbreviated mental test score include?

A
  1. Date of birth
  2. Age
  3. Time
  4. Year
  5. Place
  6. Head of state –> Who is the prime minister –> NAME is required.
  7. WWII –> What year did the WWII started?
  8. 5-minute recall –> Tell the patient an address (often 42 West street is used) and ask them 5min later to recall it.
  9. 20-1 –> Backward counting from 20 to 1.
  10. Recognition –> What job do I do? (doctor) and “What job does this man/woman do?” (nurse) –> BOTH must be correct to score a point.
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39
Q

CN I - Applied anatomy?

A
  1. Fibers arise in the mucous membrane of the nose.
  2. Axons pass across the cribriform plate to the olfactory bulb.
  3. Olfactory tract runs backwards below the frontal lobe + projects, mainly, in the uncus of the ipsilateral temporal lobe.
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40
Q

CN I - Applied anatomy - Interesting?

A

Olfactory epithelium also contains free nerve endings of the 1st division of CN V.

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41
Q

CN I - Casual exam?

A

Take a nearby odorous object (coffee, chocolate) and ask the patient if it smells normal.

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42
Q

CN I - Formal exam?

A

A series of identical bottles containing recognizable smells are used. The patient is asked to identify them.
Commonly used agents:
1. Coffee
2. Vanilla
3. Camphor
4. Vinegar
–> Test EACH nostril separately + determine if any loss of smell is uni- or bilateral.

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43
Q

Bilateral anosmia?

A

Usually NASAL, not neurological.

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44
Q

Bilateral anosmia - etiology?

A
  1. URI
  2. Trauma
  3. Smoking
  4. Old age
  5. Parkinson
  6. Less commonly tumors of the ethmoid bones or congenital ciliary dysmotility syndromes.
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45
Q

Unilateral anoma?

A
  1. Mucous-blocked nostril.
  2. Head trauma
  3. Subfrontal meningioma
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46
Q

CN I - Hints:

A
  1. Peppermint
  2. Ammonia
  3. Methanol
    stimulate the FREE TRIGEMINAL ENDINGS so are not as a good test of CN I.
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47
Q

Only part of the CNS that can be directly visualized?

A

Optic nerve begins

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48
Q

Visual acuity - Formally tested with?

A

A Snellen’s chart.

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49
Q

Visual acuity - how to exam?

A
  1. In good light, the patient should stand 6m away from the chart.
  2. Each eye is tested in turn and the patient is asked to read the chart.
  3. The number above each line indicates the distance at which a person with normal sight should be able to read it.
  4. Record the line reached - allow max of 2 errors/per line.
  5. Indicate results as: distance from chart/distance it should be read eg 6/36.
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50
Q

Visual acuity - if the patient CAN’T see any of the letters, record whether they can?

A
  1. Count Fingers held in front of their face (CF)
  2. See hand movements (wave your hand).
  3. Perceive light –> CF, HM, PL, or NPL (not perceive light).
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51
Q

Color vision?

A
  1. Not tested routinely.

2. Tested using Ishihara plates.

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52
Q

Visual field - Normal?

A

The area that the eye can see without moving is NOT CIRCULAR –> Eyebrows and nose obstruct superiorly and nasally whereas there is no obstruction laterally.

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53
Q

Gross defects and visual neglect (inattention)?

A
  1. Sit opposite the patient, 1m, eyes levels.
  2. Test first for gross defects + visual neglect with both eyes open.
  3. Raise your arms up to the sides so that one hand is in the upper right quadrant of your vision and one in the upper left.
  4. Ask patient to look directly at you (“look at my nose”).
  5. Move one index finger and ask the patient, while looking straight at you, to point to the hand which is moving.
  6. Test with the right, left, and with both hands.
  7. Test the lower quadrants in the same way.
  8. If VISUAL NEGLECT is present –> patient will be able to see each hand moving individually but reports seeing only one hand when BOTH are moving.
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54
Q

Test the eyes - if the patient is unable to cooperate?

A
  1. Like much of the neurological exam, gross defects can be seen without the patient’s cooperation (confused or drowsy).
  2. Test for response to “menace” by bringing your hand in sharply from the side, stopping just short of hitting the patient in the eye.
  3. If your hand can be seen, the patient will BLINK.
  4. Test vision on the left and the right side.
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55
Q

Tunnel vision?

A

Confusing term –> Constricted visual field, giving the impression of looking down a pipe or tunnel.

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56
Q

Tunnel vision - etiology?

A
  1. Glaucoma
  2. Retinal damage
  3. Papilledema
  4. Often “functional”
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57
Q

Enlarged blind spot?

A

Caused by papilledema.

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58
Q

Unilateral field loss?

A

Blindness in one eye caused by devastating damage to the eye, its blood supply, or optic nerve.

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59
Q

Central scotoma?

A

A hole in the visual field (macular degeneration, vascular lesion or, if bilateral, toxins).
If bilateral may indicate a very small defect in the corresponding area of the occipital cortex (MS) !!!

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60
Q

Bitemporal hemianopia?

A

Nasal half of BOTH retinas, and therefore, the temporal half of each visual field is lost (damage to the center of the optic chiasm such as a pituitary tumor, craniopharyngioma, suprasellar meningioma).

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61
Q

Binasal hemiaponia?

A

The nasal half of each visual field is lost (very rare).

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62
Q

Homonymous hemianopia?

A
  1. May be left or right.
  2. Commonly seen in stroke patients
  3. Right OR Left side in both eyes is lost.
  4. If the macula is spared –> lesion in the optic radiation.
  5. If the macula is NOT spared –> lesion in the optic tract.
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63
Q

Homonymous quadrantanopia?

A

Corresponding quarters of the vision is lost in each eye .

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64
Q

Upper quadrantanopias suggest?

A

Lesion in TEMPORAL LOBE.

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65
Q

Lower quadrantanopias suggest?

A

Lesion in the parietal lobe.

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66
Q

For a complete ophthalmoscopic exam do what?

A

It is often worth dilating the pupil by instilling a few drops of mydriatic - 1% tropicamide or 1% cyclopentolate - into the inferior conjunctival sac.
With a little practise one often finds that this is not necessary for a routine exam.

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67
Q

If you plan to dilate the pupil, ask what?

A

If they have a history of angle closure glaucoma or episodes of seeing haloes around lights at night-time.

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68
Q

Ophthalmoscopy - Exam steps?

A
  1. Performed in a dimly lit room.
  2. Ask patient to focus on distant object + keep eyes still.
  3. Look through the ophthalmoscope (OS) 30cm away from the patient and bring the light in nasally from the temporal field to land on the pupil.
  4. Dial up a hypermetropic (plus) lens on the OS to focus on the corneal surface + move in as close as possible to the patient’s eye –> By gradually decr. the power of lens –> examine cornea, iris, and lens in turn.
  5. Continue to decr. power of the lens until you can sharply focus on the retinal vessels.
  6. It is often best to pick up one of the vascular arcades in the periphery and track them in towards the optic disc.
  7. Take time to look carefully - esp. where the arteries cross veins.
  8. Ask the patient to look directly into the light of the OS to gain a view of the vascular region.
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69
Q

Normal fundus - The optic disc?

A
  1. Healthy disc is pale pink/yellow and round or slightly oval in shape.
  2. Margins between disc and surrounding retina should be crisp and well defined –> Occasionally a surrounding ring is present which may be slightly lighter or darker in color.
  3. At the centre of the disc is the physiological cup. It appears paler in color compared to the rest of the disc.
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70
Q

Normal fundus - The macular region?

A
  1. Located temporally from the optic disc.
  2. This is the region with the maximum concentration of cones.
  3. At the centre of the macula is the fovea –> tiny pit DEVOID OF BLOOD VESSELS and responsible for fine resolution.
  4. Disease involving the macula and fovea can cause devastating visual loss.
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71
Q

Normal fundus - The retinal vessels?

A
  1. The central retinal artery/vein enter and leave the globe in the center of the optic disc.
  2. Veins appear larger and darker in color in comparison to the arteries.
  3. Spontaneous venous pulsations are seen in many normal eyes.
  4. Arterial pulsations should NOT be visible in normal eyes.
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72
Q

Ophthalmoscopy - Hint?

A

View the macula by directing the light on the most sensitive part of the eye. This can often be unpleasant for the patient and will lead to more marked miosis and a restricted view.

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73
Q

Abnormal findings on fundoscopy - Optic disc swelling - Appearance?

A
  1. Raised, swollen, enlarged.
  2. Disc often appears darker in color
  3. Margins of the disc are blurred and become indistinct from the adjacent retina.
  4. Retinal vessels can be seen arching down from the raised disc towards the peripheral retina.
  5. In severe cases –> Retinal hemorrhage may be seen around the disc.
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74
Q

What does papilledema mean?

A

Swelling of the optic disc due to INCR. INTRACRANIAL PRESSURE.
Not all optic disc swelling is papilledema.

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75
Q

Optic disc swelling - etiology?

A
  1. Space occupying lesions –> Malignancy, subdural hematoma, cerebral abscess.
  2. Subarachnoid hemorrhage –> Commonly associated with vitrous hemorrhage.
  3. Chronic meningitis
  4. Idiopathic intracranial HTN
  5. Malignant HTN
  6. Ischemic optic atrophy
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76
Q

Optic disc cupping - appearance?

A
  1. Physiological cup is incr. in respect to the rest of the disc.
  2. Retinal vessels kink sharply as they emerge over the rim of the cup.
  3. Hemorrhages may be present.
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77
Q

Optic disc cupping - Etiology?

A

Most commonly one of the various types of glaucoma.

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78
Q

Optic atrophy - Appearance?

A

Pale optic disc due to loss of nerve fibers in the optic nerve head.

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79
Q

Optic atrophy - Etiology?

A
  1. Ischemic optic neuropathy
  2. Optic neuritis
  3. Trauma
  4. Optic nerve compression
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80
Q

Retinal hemorrhage - Appearance?

A
  1. Depends on its location within the various layers of the retina.
  2. Deep hemorrhages appear as “dots” due to the close packing of the cells in this region.
  3. More superficial hemorrhages in the nerve fiber layer appear as more widespread “blotches”.
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81
Q

Retinal hemorrhages - Etiology?

A
  1. DM
  2. HTN
  3. Subarachnoid hemorrhage
  4. Blood dyscrasias
  5. Systemic vasculitis
  6. Valsalva maneuver
  7. Trauma
  8. Bacterial endocarditis (known specifically as Roth spots)
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82
Q

Central/branch retinal artery occlusion - Appearance?

A
  1. Large areas of ischemic white retina associated with sudden catastrophic visual loss.
  2. Calcific, cholesterol or fibrin-platelet emboli can often be seen occluding the retina artery/branch.
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83
Q

Central/branch retinal artery occlusion - etiology?

A

Either embolic or thrombotic (remember giant cell arteritis also).

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84
Q

Central/branch retinal VEIN occlusion - appearance?

A
  1. Large, widespread flame-shaped hemorrhages –> stormy sunset.
  2. Gradual onset painless blurred vision and visual loss.
  3. Optic disc swelling may be present.
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85
Q

Central/branch retinal VEIN occlusion - etiology?

A
  1. Blood dyscrasias
  2. DM
  3. Glaucoma
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86
Q

Foster-Kennedy syndrome - appearance?

A
  1. UNILATERAL optic atrophy
  2. Contralateral papilledema
  3. Central scotoma
  4. Anosmia (variable)
  5. Systemic symptoms –> Headache, dizziness, vertigo, vomiting.
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87
Q

Foster-Kennedy syndrome - etiology?

A
  1. Meningioma of optic nerve, olfactory groove or sphenoid wing.
  2. Frontal lobe tumor.
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88
Q

Variation in the pupil size is brought about by 2 muscles in the iris under ANS?

A
  1. Sphincter pupillae muscle

2. Dilator pupillae muscle

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89
Q

Sphincter pupillae muscle?

A

Found in the iris at the margin of the pupil.

Innervated by PNS fibers –> Constricts the pupil (miosis).

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90
Q

Dilator pupillae muscle?

A

Radially arranged smooth muscle –> Innervated by SNS –> Dilates pupil (Mydriasis).

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91
Q

Pupillary light response - mechanism?

A
  1. Afferent fibers leave the eye in the optic nerve and separate in the midbrain to synapse with the 3rd nerve nuclei.
  2. Efferent pathway fibers then travel to synapse in the ciliary ganglion before innervating the sphincter pupillae.
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92
Q

Pupil - examination?

A
  1. Inspect both pupils in good light - is there a discrepancy in size (anisocoria) or shape? –> Present in 25% of normal population.
  2. May be secondary to previous ocular inflammation disease, trauma, or surgery.
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93
Q

If anisocoria is present?

A

Must determine which of the pupils is the correct size:

  1. Pathologically constricted pupil is more obvious in dim light as the normal pupil dilates.
  2. A pathologically large pupil will be more apparent n bright illumination when the normal pupil will constrict.
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94
Q

Marcus-Gunn swinging light test?

A

Assess the AFFERENT limb of the pupillary light pathway:

  1. Shine light in the normal eye and both pupils constrict –> consensual response in the affected eye is intact.
  2. Swing the light to the affected eye and both pupils dilate –> afferent drive to cause constriction of the pupils from the affected eye is reduced in comparison to that of the unaffected eye.
  3. Swing the light back to the normal eye and both pupils constrict.
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95
Q

Exam the EFFERENT limb of the pupil reflex?

A

Ask the patient to focus on a distant object and then look immediately to your index finger held 30cm in front of their face.
–> normal will be for the pupils to constrict in response to convergence and accommodation.

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96
Q

Argyll-Robertson pupil?

A
  1. Midbrain lesions caused by neurosyphilis target the more dorsally located fibers that subserve the light response.
  2. Ventrally located fibers responsible for accommodation are spared.
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97
Q

Argyll-Robertson pupil - appearance?

A

Small irregular pupil that accommodates but does NOT react to light.

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98
Q

Argyll-Robertson pupil - causes?

A
  1. Neurosyphilis

2. DM

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99
Q

Holmes-Adie pupil?

A
  1. Denervation of the Iris and ciliary body due to ciliary ganglionitis (although some would dispute this!).
  2. Associated loss of tendon reflexes is seen in some patients and is termed Holmes-Adie syndrome.
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100
Q

Holmes-Adie pupil - appearance?

A

Unilateral dilated pupil –> Accommodates and relaxes very slowly and shows absent or depressed light reflex –> Supersensitive to 0.1% pilocarpine (causing constriction).

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101
Q

Holmes-Adie pupil - etiology?

A
  1. Usually IDIOPATHIC and predominates in young adult females (2:1).
  2. May also follow iridoplegia or ocular trauma.
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102
Q

Horner’s syndrome - appearance?

A
  1. Unilateral miotic pupil with partial Ptosis (due to paralysis of Muller’s muscle - a small smooth muscle in the upper lid.
  2. Movement of the upper lid should be intact as the levator muscle is supplied by the oculomotor nerve.
  3. Variable interruption of sudomotor innervation to the ipsilateral side of the face.
  4. Sweating is absent if the lesion occurs proximal to the carotid plexus, after which the sudomotor fibers separate.
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103
Q

Horner’s syndrome - etiology?

A
  1. Protracted course of the sympathetic pathway makes it vulnerable to disruption at many different points.
  2. Congenital - often associated with an alternation in Iris pigment (heterochromia).
  3. Injury or surgery to the neck.
  4. Multiple sclerosis
  5. Cevernous sinus disease
  6. Neoplasia involving the mediastinum, cervical cord or the apex of the lung.
  7. Infarction - secondary to occlusion of the basilar or posterior inferior cerebellar artery.
  8. Thoracic aortic aneurysm
  9. Syringomyelia or syringobulbia
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104
Q

What is Klumpke’s paralysis?

A

Avulsion of the C8 and T1 roots.

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105
Q

Oculomotor - motor innervation?

A
  1. Levator palpebrae superioris
  2. Superior rectus
  3. Medial rectus
  4. Inferior rectus
  5. Inferior oblique
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106
Q

Oculomotor - autonomic?

A

PNS supply to the constrictor (sphincter) pupillae of the Iris and ciliary muscle.

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107
Q

Main oculomotor nucleus?

A

Lies anterior to the aqueduct of the midbrain.

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108
Q

Edinger-Westphal nucleus?

A

Accessory PNS nucleus –> Lies posterior to the oculomotor nucleus.
Fibers pass anteriorly, through the cavernous sinus, entering the orbit through the superior orbital fissure.

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109
Q

Trochlear - motor?

A

Superior oblique

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110
Q

Trochlear nucleus?

A
  1. Lies Inferiorly to that of the oculomotor and has connections with the cerebral hemispheres, visual cortex and nerves III, VI, VIII.
  2. Fibers pass POSTERIORLY and immediately crooks one another.
  3. They then travel through the cavernous sinus, entering the orbit through the superior orbital fissure.
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111
Q

Abducens - nucleus?

A
  1. Lies beneath the 4th ventricle.
  2. Connects with the nuclei of the III and IV through MLF.
  3. Emerges from the pons and travels through the cavernous sinus to enter the orbit through the superior orbital fissure.
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112
Q

Examination of III, IV, VI?

A
  1. Inspect position of the lids –> Epicanthic folds prominent? Ptosis?
  2. Look at the position of the eyes in neutral gaze.
  3. Asymmetrical position suggests strabismus (squint) and this should be assessed with the cover test.
  4. Ask patient to follow your index finger in vertical, horizontal, and oblique planes - avoiding extremes of gaze.
  5. Is nystagmus present?
  6. Diplopia? Ask the patient.
  7. Eyes should follow smoothly the moving target (pursuit) –> often interrupted with saccades in Parkinson/Huntington.
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113
Q

How to test saccadic eye movements?

A
  1. Now hold up your index finger on one side of their head and your thumb on the other - in their temporal visual fields.
  2. Ask the patient to look quickly between finger and thumb –> Should be accurate, smooth, rapid.
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114
Q

How to test convergence?

A

Ask the patient to look from a distant object to a near object –> the eyes should converge smoothly and equally in association with accommodation and pupil constriction.

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115
Q

Ptosis (dropping of the lid) - Causes?

A
  1. Weakness of the levator muscle in myasthenia gravis.
  2. CN III palsy
  3. Disruption of the insertion of the levator muscle into the tarsal plate of the lid either through surgery or trauma.
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116
Q

Strabismus/squint - Divergent?

A

One eye is directed towards the target, the other is turned laterally.

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117
Q

Strabismus/squint - Convergent?

A

The other eye is turned medially.

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118
Q

2 forms of squint?

A
  1. Non paralytic

2. Paralytic

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119
Q

Non paralytic squint?

A
  1. Seen in childhood

2. Both eyes have a full range of movement but only one of the eyes is directed towards the target of fixation.

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120
Q

Paralytic squint

A

Movement of one or more of the extraocular muscles is decreased due to disease of the muscle, a nerve palsy, or a physical obstruction to movement in a particular direction –> tethering, trauma, or neoplasm.

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121
Q

The cover-uncover test

A

Used for further analysis of non-paralytic squint:
1. Patient sits in front of you.
2. Present a fixation target in front of them (top of your pen for example).
3. Ask them to cover their right eye.
4. Closely observe the uncovered left eye –> One of three is possible:
a. Eye doesn’t move at all –> normal.
b. Eye moves nasally to fixate –> Divergent squint
c. Eye moves temporally to fixate –> Convergent squit
Repeat covering the left eye.

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122
Q

More sophisticated assessment of squint?

A

Using a syntophore in eye clinics.

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123
Q

Further assessment of squint?

A

Should always involve a detailed assessment of the cornea, lens, vitreous and retina to exclude opacities and abnormalities.

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124
Q

Nystagmus is?

A

Oscillating movements of the eyes.

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125
Q

Vestibular nystagmus?

A

Type of jerk nystagmus (to and fro movements are of different velocities).

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126
Q

Vestibular nystagmus - Etiology?

A

Caused by disease in the labyrinth or its central connections.

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127
Q

Vestibular nystagmus - fast phase?

A

Is away from the side of the lesion.

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128
Q

Vestibular nystagmus - features?

A
  1. Often horizontal and rotatory components.

2. Usually only present in the acute phase of labyrinthine disease.

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129
Q

Pendular nystagmus?

A
  1. The velocity of the movements is the same in BOTH directions.
  2. Often a congenital condition associated with deceased visual acuity.
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130
Q

Pendular nystagmus - seen in?

A
  1. Cerebrovascular disease

2. Multiple sclerosis

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131
Q

Oscillopsia?

A

Patients with acquired nystagmus will often complain of continual movement of their visual environment, which is NOT the case with congenital nystagmus.

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132
Q

Optokinetic nystagmus?

A

This is a normal response of the eye when trying to follow a moving object - when looking from the window of a train.

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133
Q

Defective optokinetic nystagmus seen in?

A

Lesions of the deep parietal lobe when drum rotation is towards the affected hemisphere.

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134
Q

Upbeat nystagmus?

A

The fast phase is upwards.

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135
Q

Upbeat nystagmus - etiology?

A
  1. Brainstem disease

2. Intoxication with alcohol and a number of other drugs including phenytoin.

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136
Q

Downbeat nystagmus?

A

The fast phase is downwards.

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137
Q

Downbeat nystagmus - seen in?

A
  1. In toxic states and Demyelinating diseases.

2. Herniation of cerebellar tissue through the Foramen magnum as seen in Chiari malformation.

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138
Q

Gaze-evoked nystagmus?

A

The fast phase is towards the direction of action of the affected muscle.

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139
Q

Gaze-evoked nystagmus - seen in?

A

In dysfunction of extraocular muscles secondary to intrinsic weakness or nerve palsy.

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140
Q

Hint about nystagmus exam?

A

When assessing nystagmus try to avoid the extremes of lateral gaze (I.e. Not >30 degrees) –> This will elicit end-point nystagmus - a physiological response not to be confused with a pathological process.

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141
Q

Oculomotor palsy - Appearance?

A
  1. Pupil dilated and response to neither light nor accommodation.
  2. All the extraocular muscles are paralyzed except for the lateral rectus and the superior oblique.
  3. Unopposed action of these cause the eye to look DOWN AND OUT.
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142
Q

Paralysis of the levator palpebrae muscle causes?

A

COMPLETE ptosis.

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143
Q

Oculomotor palsy - etiology?

A
  1. DM (pupil sparing)
  2. Lesions involving the superior orbital fissure.
  3. Cavernous sinus disease
  4. Aneurysm of posterior communicating artery
  5. Weber syndrome (associated CONTRALATERAL hemiplegia)
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144
Q

Palsy of trochlear nerve - appearance?

A
  1. Paralysis of the superior oblique causes the eye to elevate when adducting.
  2. Patient complains of Diplopia and will have difficulty looking downwards and inwards on the affected side.
  3. Patient may try to compensate for this by tilting their head away from the side of the lesion –> Ocular torticollis.
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145
Q

Causes of trochlear nerve palsy?

A
  1. Trauma
  2. Surgery
  3. DM
  4. Atherosclerosis
  5. Neoplasia
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146
Q

Abducens palsy - appearance?

A
  1. Paralysis of the lateral rectus muscle means the eye cannot be abducted from the midline and the unopposed action of the medial rectus leaves the eye deviated NASALLY at rest.
  2. Patient complains of Diplopia in horizontal gaze.
  3. Lesions in the 6th nerve nucleus also involve the lateral gaze centre and lead to gaze paresis.
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147
Q

Abducens nerve palsy - Etiology?

A
  1. DM
  2. Atherosclerosis
  3. MS
  4. Neoplastic lesions
  5. Raised intracranial pressure leading to compression of the nerve on the edge of the petrous temporal bone (a false localizing sign).
  6. Trauma
  7. Surgery
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148
Q

Combined nerve palsies - The cavernous sinus?

A

All 3 nerves involved in Oculomotor control along with sympathetic fibers to the Iris and the ophthalmic and maxillary divisions of the trigeminal nerve pass through here.

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149
Q

Common lesions of the cavernous sinus?

A
  1. Carotid-cavernous fistula
  2. Expanding pituitary tumor
  3. Cavernous sinus thrombosis - associated with proptosis and injection of conjunctival vessels (chemosis)
  4. Aneurysm
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150
Q

Combined nerve palsies - The orbit?

A
  1. A complex range of Ophthalmoplegias can result from any compressive lesion located within the orbit.
  2. Proptosis may be present with variable optic nerve involvement.
  3. Many lesions may directly impinge upon the extraocular muscles as well as the innervating nerves.
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151
Q

Combined nerve palsies - Superior orbital fissure?

A
  1. Transmits all the nerves supplying the extraocular muscles along with the ophthalmic division of the trigeminal nerve.
  2. Inflammation or a lesion at the superior orbital fissure leads to Tolosa-Hunt syndrome.
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152
Q

Tolosa-Hunt syndrome?

A

A complex unilateral ophthalmoplegia associated with anesthesia over the forehead and ocular pain.

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153
Q

Internuclear ophthalmoplegia of III, IV, VI?

A

This is interruption of the MLF, connecting the nuclei of cranial nerves III and VI on opposite sides.

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154
Q

Internuclear ophthalmoplegia of III, IV, VI - Appearance?

A
  1. Impaired adduction in the IPSILATERAL eye in unilateral lesions -nystagmus is often seen in the abducting eye.
  2. Bilateral lesions often cause vertical nystagmus and impaired vertical pursuit.
  3. Convergence remains intact.
  4. Patient will complain of horizontal Diplopia due to impaired adduction on the affected side - not due to nystagmus in the abducting eye.
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155
Q

Internuclear ophthalmoplegia III, IV, VI - Etiology?

A
  1. Cerebrovascular disease

2. Multiple sclerosis.

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156
Q

Lesions of the parapontine reticular formation?

A

The PPRF is responsible for conjugate eye movements in horizontal gaze.

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157
Q

Lesions of the PPRF - Appearance?

A
  1. Failure of horizontal eye movements towards the side of the lesion - Horizontal gaze paresis.
  2. An ipsilateral Internuclear ophthalmoplegia if the lesion extends to involve the MLF.
  3. Preservation of vertical gaze.
  4. Contralateral deviation of the eyes in the acute phase.
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158
Q

Lesions of the parapontine reticular formation?

A
  1. Vascular disease
  2. Demyelinating disease
  3. Neoplasia
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159
Q

Parinaud’s syndrome?

A

Lesions occurring in the dorsal midbrain involve the vertical gaze centre - hence also known as dorsal midbrain syndrome.

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160
Q

Parinaud’s syndrome - Appearance?

A
  1. Impaired upward gaze in both eyes resulting in convergence, retraction of the globe into the orbit and nystagmus.
  2. Light-near dissociation of the pupils - The near reflex is intact but response to light is poor.
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161
Q

Parinaud’s syndrome - Etiology?

A
  1. Demyelinating disease
  2. Vascular disease affecting the dorsal midbrain
  3. Enlarged 3rd ventricle
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162
Q

Cranial nerve V - Applied anatomy - Sensory?

A

Facial sensation in 3 branches: V1, V2, V3.

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163
Q

CN V - Applied anatomy - Motor?

A

Muscles of mastication.

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164
Q

CN V - Exam - Inspection?

A

Inspect the patient’s face –> Wasting of the Temporalis will show as hollowing above the zygomatic arch.

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165
Q

CN V - Testing motor function?

A
  1. Ask patient to clench their teeth and feel both sides for the bulge of the Masseter and Temporalis.
  2. Ask the patient to open their mouth wide –> The jaw will deviate towards the side of the V lesion.
  3. Again ask them to open their mouth but provide resistance holding their jaw closed with one of your hands.
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166
Q

CN V - Testing sensory function?

A
  1. Assess light-touch for each branch and ask the patient to say ‘yes’ if they can feel it.
  2. For each branch, compare left to right. Ignore minor differences.
  3. Test pin-prick sensation at the same spots using a sterile pin.
  4. Temperature sensation is not routinely tested - Consider only if abnormalities in light touch and pin-prick are found.
  5. Use specimen tubes or other small containers full of hot or cold water.
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167
Q

CN V - Findings?

A
  1. Wasting of muscles
  2. Loss of ALL sensory modalities
  3. Loss of light touch only
  4. Loss of light-touch in V only
  5. Loss of pin-prick only
  6. Loss of sensation in a muzzle distribution (nose, lips, anterior cheek)
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168
Q

CN V - Wasting of muscles indicate?

A
  1. Long-term V palsy
  2. MND
  3. Myotonic dystrophy
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169
Q

CN V - Loss of ALL sensory modalities indicate?

A

V ganglion lesion (herpes zoster?)

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170
Q

CN V - Loss of light touch only?

A

With loss of sensation on ipsilateral side of the body –> contralateral parietal lobe (sensory cortex) lesion.

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171
Q

Loss of light touch in V only?

A

Lesion at sensory root pons.

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172
Q

Loss of pin-prick only?

A

Along with contralateral side of the body –> ipsilateral brainstem lesion.

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173
Q

Loss of sensation in a “muzzle” distribution (nose, lips, anterior cheeks)?

A

Damage to the lower part of the spinal sensory nucleus –> syringomyelia, demyelination.

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174
Q

CN V - Reflexes - Jaw jerk?

A
  1. Explain to the patient what is about to happen as this could appear rather threatening!
  2. Ask the patient to let their mouth hang loosely open.
  3. Place your finger horizontally across their chin and tap your finger with a patella hammer.
  4. Feel and watch jaw movement –> Should be a light closure but this varies widely in normal people.
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175
Q

CN V - Reflexes - Corneal reflex limbs?

A 
Afferent = V1
Efferent = VII
176
Q

CN V - Reflexes - Corneal reflex exam?

A
  1. Ask the patient to look up and away from you.
  2. Gently touch the cornea with a wisp of cotton wool.
  3. Bring this in from the side so it cannot be seen approaching.
  4. Watch both eyes. A blink is a normal response.
    - -> No response = Ipsilateral V1 palsy.
    - -> Lack of blink on one side only = VII palsy.
  5. Watch out for contact lenses! –> Will give reduced sensation - Ask the patient to remove them first.
177
Q

CN V exam hints:

A
  1. Note the sensory distribution! The angle of the jaw is NOT supplied by V3 but by the great auricular nerve (C2, C3).
  2. When testing the corneal reflex, touch the cornea (overlies the iris), not the conjunctiva (overlies the sclera).
178
Q

CN VII - Applied anatomy - Sensory?

A
  1. External auditory meatus
  2. Tympanic membrane
  3. Small portion of skin behind the ear.
  4. Special sensation: Taste anterior 2/3 of tongue.
179
Q

CN VII - Applied anatomy - Motor?

A
  1. Muscles of facial expression

2. Stapedius

180
Q

CN VII - Applied anatomy - Autonomic?

A

PNS supply to lacrimal glands.

181
Q

CN VII - Applied anatomy - Special features?

A
  1. Nucleus lies in the pons - nerve leaves at the cerebellopontine angle with VII.
  2. Nerve gives off a branch to the stapedius at the geniculate ganglion while the majority of the nerve leaves the skull via the stylomastoid foramen and travels through the parotid gland.
182
Q

CN VII exam - Muscles of facial expression?

A
  1. Look at the patient’s face at rest. Look for asymmetry in the nasolabial folds, angles of the mouth and forehead wrinkles.
  2. Ask the patient to raise their eyebrows (“look up!”) and watch the forehead wrinkle.
  3. Attempt to press their eyebrows down and note any weakness.
  4. Ask the patient to “close your eyes tightly”.
  5. Ask the patient to blow out their cheeks. Watch for air escaping on one side.
  6. Ask the patient to bare their teeth. “Show me your teeth!” Look for asymmetry.
  7. Ask the patient to pursue their lips. “Whistle for me!” Look for asymmetry. The patient will always smile after whistling.
183
Q

The “whistle-smile” sign?

A

A failure to smile when asked to whistle is usually due to emotional paresis of the facial muscles and is synonymous with Parkinsonism.

184
Q

CN VII exam - External auditory meatus?

A

This should be examined briefly if only VII examined - can be done as part of VII if examining all the cranial nerves.

185
Q

CN VII - Taste?

A

Rarely tested outside specialist clinics.

  1. Each side is tested separately by using cotton buds dipped in the solution of choice applied to each side of the tongue in turn.
  2. Be sure to swill the mouth with distilled water between each taste sensation.
  3. Test: sweet, salty, bitter (quinine), and sour (vinegar).
186
Q

CN VII Exam findings - UMN lesion?

A
  1. Will cause loss of facial movement on the ipsilateral side but with preservation of forehead wrinkling.
  2. Both sides of the forehead receive bilateral nervous supply.
    Unilateral –> CVA etc.
    Bilateral –> Pseudobulbar palsy, motor neuron disease.
187
Q

CN VII Exam findings - Lower motor neuron lesion?

A

Will cause loss of all movement on the ipsilateral side of the face.

188
Q

CN VII - UNILATERAL lower motor lesion - etiology?

A
  1. Deemyelination
  2. Tumors
  3. Bell’s palsy
  4. Pontine lesions
  5. Cerebellopontine angle lesions
189
Q

CN VII - BILATERAL lower motor neuron lesion - etiology?

A
  1. Sarcoidosis
  2. GBS
  3. Myasthenia gravis
190
Q

CN VII - Bell’s palsy?

A

Idiopathic unilateral LMN VII paresis.

191
Q

Ramsay-Hunt syndrome?

A

Unilateral paresis causes by herpes at the geniculate ganglion –> look for herpes rash on the external ear.

192
Q

CN VII Exam Hints:

A
  1. Bell’s phenomenon is the upward movement of the eyeballs when the eye closes.
  2. This occurs in the normal state but can be clearly seen if the eyelids fail to close due to VII palsy.
  3. VII palsy does NOT cause eyelid ptosis.
  4. Longstanding VII palsy can cause fibrous contraction of the muscles on the affected side resulting in more pronounced nasolabial fold (the reverse of the expected findings).
  5. BILATERAL VII palsy will cause a sagging, expressionless face and is often missed.
193
Q

CN VIII - Applied anatomy - Sensory?

A
  1. Hearing

2. Balance/Equilibrium

194
Q

CN VIII - Applied anatomy - Motor?

A

NONE

195
Q

Cochlear branch course?

A

Originates in the organ of Corti –> Passes though the internal auditory meatus to its nucleus in the pons –> Fibers pass to the superior gyrus of the temporal lobes.

196
Q

Vestibular branch route?

A

Arises in the utricle and semicircular canals –> Joins the auditory fibers in the facial canal –> Enters the brainstem at the cerebellopontine angle and ends in the pons and cerebellum.

197
Q

CN VIII - Exam?

A
  1. Enquire first about symptoms.
  2. Hearing loss/changes or balance problems.
  3. Peripheral vestibular lesions cause ataxia during paroxysms of vertigo but not at other times.
198
Q

Hearing exam?

A

Test each ear separately - Cover one by pressing on the tragus or create white-noise by rubbing your fingers together at the external auditory meatus.

199
Q

Simple test of hearing?

A
  1. Whisper a number into one ear and ask the patient to repeat it.
  2. Repeat with the other ear.
  3. Be careful to whisper at the same volume in each ear (the end of expiration is best) and at the same distance (about 60cm).
200
Q

Rinne’s test?

A
  1. Tap a 512Hz tuning fork and hold adjacent to the ear (air conduction).
  2. Then apply the base of the tuning fork to the mastoid process (bone conduction).
  3. Ask the patient which position sounds louder.
    Normal –> Air conduction > Bone conduction = Rinne’s positive.
    In neural (or perceptive) deafness, Rinne’s test will remain positive.
    In conductive deafness –> Bone > Air.
201
Q

Weber’s test?

A
  1. Tap a 512Hz tuning fork and hold the base against the vertext or forehead at the midline.
  2. Ask the patient if it sounds louder on one side.
    - -> Neural deafness –> Tone is heard better in the intact ear.
    - -> Conductive deafness –> Tone is heard better in the affected ear.
202
Q

Vestibular function - Turning test?

A
  1. Ask the patient to stand facing you, arms outstretched.
  2. Ask them to march on the spot, then close their eyes (continue marching).
  3. Watch!
    - -> Patient will gradually turn toward the side of the lesion - sometimes will turn right around 180.
203
Q

Halpike’s manoeuvre?

A

A test for benign positional vertigo (BPV). Do NOT test those with known neck problems or possible circulation impairment.

204
Q

Hallpike’s manoeuvre - steps?

A
  1. Warn the patient about what is to happen.
  2. Sit the patient facing away from the edge of the bed such that when they lie back their head will not be supported (over the edge).
  3. Turn their head to one side and ask them to look in that direction.
  4. Lie them back quickly - Supporting their head so that it lies about 30 degrees below the horizontal.
  5. Watch for nystagmus –> affected ear will be lowermost.
  6. Repeat with the head turned in the other direction.
205
Q

Hallpike’s manoeuvre - results?

A
  1. NO nystagmus = normal.
  2. Nystagmus, with a slight delay (10sec) and fatiguable (can’t be repeated successfully for 10-15min) = BPV.
  3. Nystagmus, no delay, no fatigue = Central vestibular syndrome.
206
Q

CN IX - Applied anatomy - Sensory?

A
  1. Pharynx
  2. Middle ear
  3. Special sensation: Taste on posterior 1/3 of tongue.
207
Q

CN IX - Applied anatomy - Motor?

A

Stylopharyngeous musclee

208
Q

CN IX - Autonomic?

A

Parotid gland

209
Q

CN IX route?

A

Originates in the medulla –> Passes through the jugular foramen.

210
Q

CN X - Applied anatomy - Sensory?

A
  1. Tympanic membrane
  2. External auditory canal
  3. External ear
  4. Also proprioception from thorax and abdomen
211
Q

CN X - Motor?

A
  1. Palate
  2. Pharynx
  3. Larynx
212
Q

CN X - Autonomic?

A

Carotid baroreceptors

213
Q

CN X - Route?

A

Originates in medulla and pons, leaves the skull via jugular foramen.

214
Q

Examination - Pharynx?

A
  1. Ask the patient to open their mouth and inspect the uvula (use a tongue depressor if necessary) –> Central or deviated to one side? If so, which side?
  2. Ask the patient to say “aah”. Watch the uvula –> Should move upwards centrally. Does it deviate to one side?
215
Q

Gag reflex limbs?

A 
Afferent = IX
Efferent = X
216
Q

Gag reflex - exam steps?

A
  1. With the patient’s mouth open wide, gently touch the posterior pharyngeal wall on one side with a tongue depressor or other sterile stick.
  2. Watch the uvula (it should lift up).
  3. Repeat on the opposite side.
  4. Ask the patient if they felt the 2 touches - and was there any difference in sensation?
217
Q

Larynx - exam steps?

A
  1. Ask the patient to cough - normal character? Gradual onset/sudden?
  2. Listen to the patient’s speech - note volume, quality and whether it appears to fatigue (quieter as time goes on).
  3. Test shallow.
218
Q

CN IX, X - Findings - Uvula?

A
  1. Moves to one side = X lesion on the opposite side.
  2. No movement = muscle paresis.
  3. Moves with “aah” but not gag and decr. pharyngeal sensation = IX palsy
219
Q

CN IX, X - Findings - Cough?

A
  1. Gradual onset of a deliberate cough = vocal cord palsy.
  2. ‘Wet’, bubbly voice and cough palsy (X palsy).
  3. Poor shallow and aspiration = combined IX and X or lone X lesion.
220
Q

CN XI - Origin and route?

A
  1. Cranial part –> from nucleus ambiguus in the medulla.
  2. Spinal part –> from the lateral part of the spinal cord down to C5 as a series of rootlets.
  3. These join together and ascend adjacent to the spinal cord, passing through the foramen magnum to join with the cranial portion of the accessory nerve.
  4. It leaves the skull via the jugular foramen.
  5. Cranial portion joins with the X.
  6. Spinal portion innervates SCM and the upper fibers of the trapezii.
    NOTE –> Each cerebral hemisphere controls IPSILATERAL SCM and the CONTRALATERAL trapezius.
221
Q

CN XI - Exam steps?

A
  1. Cranial portion cannot be tested separately.
  2. Inspect the SCM - Look for wasting, fasciculations, hypertrophy, and any abnormal head position.
  3. Ask the patient to shrug their shoulders and observe.
  4. Ask the patient to shrug again, using your hands on their shoulders to provide resistance.
  5. Ask the patient to turn their head to each side, first without and then with resistance (use your hand on their cheek).
222
Q

CN XI - Findings?

A
  1. Isolated lesions are very rare.
  2. Bilateral weakness –> wasting caused by muscular problems or motor neuron disease.
  3. Unilateral weakness –> Trapezius and SCM same side –> suggests peripheral neurological lesion.
  4. Unilateral weakness –> Trapezius and SCM of opposite sides –> usually seen with hemiplegia suggests an UMN lesion IPSILATERAL to the weak sternomastoid.
223
Q

CN XI - Exam Hints?

A
  1. Remember that the action of the SCM is to turn the head to the OPPOSITE SIDE –> Poor head turning to the LEFT indicates a weak RIGHT SCM.
  2. When providing resistance to head turning, be sure to press against the patient’s cheek. Lateral pressure to the jaw can cause pain and injury, particularly in the elderly and frail.
224
Q

CN XII - Applied anatomy - Motor?

A

Muscles of the tongue.

225
Q

CN XII - Nucleus and route?

A

Nucleus lies on the floor of IV ventricle –> Fibers pass ventrally, leaving the brainstem lateral to the pyramidal tracts –> Leaves the skull via the hypoglossal foramen.

226
Q

CN XII - Examination?

A
  1. Ask the patient to open wide and inspect the tongue on the floor of the mouth –> Look for size and evidence of fasciculation.
  2. Ask the patient to protrude the tongue –> Look for deviation or abnormal movements.
  3. Ask the patient to move the tongue in and out repeatedly, then side-to-side.
  4. To test subtle weakness, place your finger on the patient’s cheek and ask them to push against it from the inside using their tongue.
227
Q

CN XII - Findings - LMN lesion?

A

Will cause fasciculations on the affected side and a deviation towards the AFFECTED side on protrusion.
–> ALSO there be a weakness on pressing the tongue away from the affected side.

228
Q

CN XII - Findings - Unilateral upper motor neuron lesion?

A

Will rarely cause any clinically obvious signs.

229
Q

CN XII - Findings - Bilateral UMN lesion?

A

Will give a small, globally weak tongue with reduced movements.

230
Q

CN XII - Findings - Bilateral LMN lesion (eg motor neuron disease)?

A

Will ALSO produce a small, weak tongue.

231
Q

CN XII - Findings - A rapid “in and out” movement on protrusion?

A

Trombone tremor –> Can be caused by:

  1. Cerebellar disease
  2. Extra-pyramidal syndromes
  3. Essential tremor
232
Q

CN XII - Exam hints:

A
  1. Rippling movements may be seen if the tongue is held protruded for long periods.
  2. This is normal and should NOT be mistaken for fasciculations.
233
Q

Motor: inspection and tone - Inspection?

A
  1. Any walking aids or abnormal gait?
  2. Shake hands - abnormalities of movements? Strength? Relaxation?
  3. Any abnormal movements when sitting?
  4. Any obvious weaknesses (eg hemiplegia)?
  5. Does the patient have good sitting balance?
234
Q

Look at the muscle groups for?

A
  1. Abnormal positioning - Due to weakness or contractures.
  2. Wasting
  3. Fasciculation (irregular contractions of small areas of muscle).
  4. Make a point of inspecting the shoulder girdle, small muscles of the hand, quadriceps, anterior compartment of lower leg and ankle.
  5. Look at the foot for contractures or abnormalities of shape.
235
Q

Muscle tone - exam techniques?

A
  1. Aim is to test the resting tone in the limbs. This takes practise and the feel of normal, incr. or decr. tone can only be taught through experience.
  2. Telling the patient to relax usually has the OPPOSITE effect!
  3. They can be distracted by a counting task or told to relax the limb “as if you’re asleep”.
  4. Light conversation is a generally successful ploy.
  5. You should also repeat the following manoeuvres at different speeds and intervals to catch the patient at an unguarded moment.
236
Q

Motor: inspection and tone - Arms exam?

A

Take the patient’s hand in yours (as if shaking it) and hold their elbow with your other hand. From this position you can:

  1. Pronate/supinate the patient’s forearm.
  2. Roll the patient’s wrist through 360 degrees.
  3. Flex and extend the patient’s elbow.
237
Q

Legs exam - Hip?

A

With the patient lying flat, legs straight, hold onto the patient’s knee and roll it from side to side.

238
Q

Legs exam - Knee?

A

With the patient in the same position, put your hand behind the patient’s knee and raise it quickly.
Watch the heel - it should lift from the bed/couch slightly if tone is normal.

239
Q

Legs exam - Ankle?

A

Holding the foot and the lower leg, flex and dorsiflex the ankle.

240
Q

Motor: inspection and tone - Findings?

A
  1. Normal tone –> Slight resistance in movement.
  2. Decr. tone –> “Flaccid” due to LMN or cerebellar lesions or myopathies.
  3. Incr. tone –> Spasticity, rigidity, Gegenhalten, myotonia, dystonia.
241
Q

Incr. tone - Spasticity?

A

Clasp-knife rigidity - The limb appears stiff. With incr. pressure, there is sudden “give” and the limb moves.
–> UMN lesions.

242
Q

Incr. tone - Rigidity (lead-pipe)?

A

The limb is equally stiff through all movements.

243
Q

Incr. tone - Rigidity (cogwheel)?

A

An extrapyramidal sign, caused by a tremor superimposed on a rigid limb. The limb moves in a stop-go halting fashion.

244
Q

Incr. tone - Gegenhalten?

A

Paratonia - Seen in bilateral frontal lobe damage and catatonic states.
Tone incr. with incr. pressure from the examiner.
–> The patient appears to be resisting movement.

245
Q

Incr. tone - Myotonia?

A

A slow relaxation after action.
When asked to make a fist, the patient is unable to release it quickly and will be slow to let go of a hand-shake (eg myotonic dystrophy).

246
Q

Incr. tone - Dystonia?

A

The limb or head has an abnormal posture that looks rather uncomfortable.

247
Q

Muscles of the face - Exam?

A

Examiner should demonstrate each movement, mirroring the patient.

248
Q

MRC power classification?

A

Medical Research Council power classification:
5 –> Normal power
4 –> Movement against resistance but not normal
3 –> Movement against gravity, but not against resistance
2 –> Movement with gravity eliminated (eg can move leg side-to-side on bed but not lift it).
1 –> Contractions but no movement seen.
0 –> No movement.

249
Q

Shoulder abduction?

A

C5:
Ask the patient to abduct their arms and elbows bent. “Arms up like a chicken!”. Ask them to hold still as you attempt to push their arms down.

250
Q

Shoulder adduction?

A

C6, C7:

The patient should hold their arms tightly to their sides with elbows bent. You attempt to push their arms out.

251
Q

Elbow flexion?

A

C5, C6:
The patient should hold their elbows bent and supinated in front of them.
Hold the patient at the elbow and wrist and attempt to extend their arm.
“Don’t let me straighten your arm!”

252
Q

Elbow extension?

A

C7:
Patient holds position above as you resist extension at the elbow by pushing on their distal forearm/wrist.
“Push me away!”

253
Q

Wrist flexion?

A

C6, C7:
With arms supinated, the patient should flex the wrist and hold as you attempt to extend it by pulling from your own wrists.

254
Q

Wrist extension?

A

C6, C7:

The opposite manoeuvre to that above. The patient holds their hand out straight and resists your attempts to bend it.

255
Q

Fingers flexion?

A

C8:
Ask the patient to squeeze your fingers or BETTER ask the patient to grip your fingers palm-to-palm and resist your attempts to pull their hand open.

256
Q

Fingers extension?

A

C7, C8:
Ask the patient to hold their fingers out straight - you support their wrist with one hand and attempt to push their fingers down with the side of your hand over their 1st interphalangeal joints.

257
Q

Fingers abduction?

A

T1:

Ask the patient to splay their fingers out and resist your attempts to push them together.

258
Q

Fingers adduction?

A

T1:
Holding the patient’s middle, ring, and little finger with one hand and their index with the other, ask the patient to pull their fingers together.
OR place a piece of paper between their out-stretched fingers and ask them to resist your attempts to pull it away.

259
Q

Pronator drift?

A

A useful test of subtle weakness.
Patient is asked to hold their arms outstretched in front, palms upwards and eyes closed. If one side is weak, the arm will pronate and slowly drift downwards.

260
Q

Hip flexion?

A

L1, L2, L3:
With the lower limbs lying on the bed/couch, the patient is asked to raise each leg, keeping the knee straight.
Examiner can oppose the movement by pushing down on the thigh just above the knee.
“Stop me from pushing down!”

261
Q

Hip extension?

A

L5, S1:
Ask the patient to keep their leg pressed against the bed as you attempt to lift it - either with a hand beneath the calf or the ankle.
“Stop me lifting your leg up!”

262
Q

Hip abduction?

A

L4, L5, S1:
Ask the patient to move their leg out to the side as you oppose the movement with a hand on the lateral thigh.
“Stop me pushing your legs together!”

263
Q

Hip adduction?

A

L2, L3, L4:
With the legs central, put your hand on the medial thigh and attempt to pull the leg out to the side against resistance.
“Don’t let me pull your legs apart!”

264
Q

Knee flexion?

A

L5, S1:

  1. Take hold of the patient’s knee with one hand and their ankle with the other and flex the leg to about 60 degrees.
  2. Patient may think you want them to resist this so often a quick instruction “bend at the knee” is required.
  3. Ask the patient to bend their leg further (“stop me straightening your leg out”) and oppose the movement at their ankle.
265
Q

Knee extension?

A

L3, L4:

  1. With the patient’s leg in the position above, ask the patient to extend their leg (“push me away”, “straighten your leg out”) as you oppose it.
  2. Alternatively, attempt to bend the patient’s leg from a straightened starting position.
266
Q

Ankle plantar flexion?

A

S1, S2:
With the patient’s leg out straight and ankle relaxed, put your hand on the ball of the foot and ask the patient to push you away.
“Push down and stop me pushing back!”.

267
Q

Ankle dorsiflexion?

A

L4, L5:

  1. From the starting position above, hold the patient’s foot just above the toes and ask them to pull their foot backwards.
  2. Patients may often attempt to move their entire leg here so “cock your foot back and stop me pushing your foot down” with an accompanying hand gesture helps.
268
Q

Tendon reflexes - LMN lesions or myopathies?

A

Reflex is absent or decreased.

269
Q

Tendon reflexes - UMN lesions or myopathies?

A

Reflexes are increased or ‘brisk’.

270
Q

Biceps exam?

A

C5, C6:

  1. With the patient seated, lie their arms across their abdomen.
  2. Place your thumb across the biceps tendon and strike it with the tendon hammer.
  3. Watch the biceps for contraction.
271
Q

Supinator exam?

A

C5, C6:

  1. The muscle tested is actually the brachioradialis.
  2. With the patient’s arms lying loosely across their abdomen, put your fingers on the radial tuberosity and tap with the hammer.
  3. The arm will flex at the elbow.
  4. If brisk, the fingers may also flex.
272
Q

Triceps exam?

A

C7:

  1. Taking hold of the patient’s wrist, flex their arm to 90 degrees.
  2. Tap the triceps tendon about 5cm superior to the olecranon process of the ulna.
  3. Watch the triceps.
273
Q

Fingers exam?

A

C8:

  1. This is only present if tone is pathologically increased.
  2. With your palm up and the patient’s arm pronated, lie the fingers on yours.
  3. Strike the back of your fingers.
  4. The patient’s fingers will flex.
274
Q

Knee exam?

A

L3, L4:

  1. With the patient’s leg extended, use one hand behind their knee to lift their leg to 60 degrees.
  2. Tap the patella tendon and watch the quadriceps.
  3. If brisk, proceed to testing for clonus here.
275
Q

Knee clonus exam?

A
  1. With the patient’s leg extended , place your thumb and index finger over the superior edge of the patella.
  2. Create a sudden downward (toward the feet) movement, and HOLD.
  3. Watch the quadriceps.
  4. Any beat of clonus here is abnormal.
276
Q

Ankle exam?

A

S1, S2:

  1. With the hip flexed and externally rotated and the knee flexed to 90 degrees, hold the foot and tap the Achilles tendon.
  2. Watch the calf muscles for contraction/ankle flexion.
  3. Alternatively, with the leg extended and relaxed, place your hand on the ball of the foot and strike your hand with the hammer.
277
Q

Reinforcement?

A

If the reflex is ABSENT, it can sometimes be elicited by asking the patient to perform a ‘reinforcing’ action which acts to increase the activity of neurons in the spinal cord.
–> Short-lived, however you should aim to test the reflex in the first 10sec of the reinforcement.

278
Q

How to reinforce?

A

For upper limb reflexes –> Ask the patient to clench their teeth.
For lower limb reflexes –> Ask the patient to lock their fingers together, pulling in opposite directions.

279
Q

Recording tendon reflexes?

A 
0 = Absent
\+/- = Present only with reinforcement
1+ = Decr./less than normal
2+ = Normal
3+ = Brisk/more than normal
280
Q

Abdominal reflex exam - Where is it less obvious?

A
  1. Children
  2. Elderly
  3. Multiparous patients
  4. Those who had abdominal surgery
  5. Obese
281
Q

Abdominal reflex exam - steps?

A
  1. Patient should be lying on their back, relaxed, abdomen exposed.
  2. Using an orange stick or similar, stroke each of the 4 segments of the abdomen, in a brief movement towards the umbilicus.
  3. As each segment is stroked, the abdominal muscles will reflexly contract.
  4. Summarize the findings diagrammatically using a simple 2x2 grid and indicating the presence or absence of a response by marking “+” and “-“ respectively. (+/- for intermediate response).
282
Q

Abdomen upper and lower segments - Dermotomes?

A

Upper –> T8-T9

Lower –> T10-T11

283
Q

Cremasteric reflex exam?

A

L1, L2:

  1. With the male patient standing and naked from the waist down, you should lightly stroke the upper aspect of their inner thigh.
  2. The ipsilateral cremaster muscle contracts and the testicle will briefly rise.
284
Q

Plantar response exam?

A

L5, S1, S2:

  1. Patient should be lying comfortably, legs outstretched.
  2. Warn the patient that you are about to touch the sole of their foot.
  3. Stroke the patient’s sole.
  4. You should stroke from the heel, up the lateral aspect of the sole to the base of the 5th toe. If there is no response, the stroke can be continued along the ball of the foot to the base of the big toe.
  5. Watch the big toe for its INITIAL movement.
    - -> NORMAL is FLEXION of the big toe.
    - -> UMN lesions will DORSIFLEX the big toe –> THIS IS THE BABINSKI RESPONSE !!!
285
Q

Plantar response - Documentation of findings?

A
  1. Down Arrow for plantar flexion.
  2. Up Arrow for dorsiflexion.
    • for an absent response.
286
Q

Plantar response exam - withdrawal response?

A

If the leg is withdrawn and the heel moves in a “ticklish” reaction, this is called a “withdrawal” response and the test should be repeated.

287
Q

Ankle clonus?

A

A rhythmical contraction of a muscle when suddenly stretched - a sign of HYPERREFLEXIA due to UMN lesion.

288
Q

Ankle clonus exam - steps?

A
  1. With the patient lying on the bed, knee straight and thigh slightly externally rotated, suddenly dorsiflex the foot.
  2. More than 3 beats of clonus - as long as the foot is dorsiflexed - is ABNORMAL.
289
Q

Primitive reflexes?

A
  1. These are reflexes seen in the newborn.
  2. May still be present in a few normal adults.
  3. They return somewhat in the elderly but are seen mainly in frontal lobe disease and encephalopathy.
    Not routinely tested, unless looking specifically for frontal lobe signs or Parkinson’s disease.
290
Q

Glabellar tap exam?

A
  1. Using your index finger, repeatedly tap (gently) the patient’s forehead between the eyebrows.
  2. If normal, the patient will blink only in the first 3 or 4 taps.
291
Q

Palmo-mental reflex exam?

A
  1. You should stroke the patient’s palm, using sharp firm pressure from the radial side to the ulnar.
  2. Watch the patient’s chin.
  3. If the reflex is present, there will be a contraction of the ipsilateral mentalis seen in the neck and chin.
292
Q

Grasp reflex exam?

A
  1. Gently stroke your fingers over the patient’s palm in a radial-ulnar direction, telling the patient NOT to grip your hand.
  2. If present, the patient will involuntarily grasp your hand and seemingly refuse to let go.
293
Q

Snout (or pout) reflex exam?

A
  1. With the patient’s eyes closed, gently tap their lips with your fingers or (very cautiously) with a patellar hammer.
  2. An involuntary puckering of the lips is a positive reflex.
294
Q

Suckling reflex exam?

A
  1. With the patient’s eyes closed, gentle stimulation at the corner of their mouth will result in a suckling action at the mouth.
  2. The patient’s head may also turn towards the stimulus.
295
Q

Dermotome is?

A

The are of skin supplied by the sensory neurons corresponding to each spinal level can be mapped out - each segment called a dermotome.

296
Q

2 main spinal pathways for sensory impulses?

A
  1. Posterior columns

2. Spinothalamic tract

297
Q

Posterior columns - senses?

A
  1. Light touch
  2. Proprioception
  3. Vibration
  4. Stereognosis (ability to recognize an object by touch)
  5. Weight discrimination
  6. Kinesthesia (perception of movement)
298
Q

Spinothalamic tract - senses?

A
  1. Pain

2. Temperature

299
Q

Dermotomes - Important landmarks?

A
  1. C7 –> Covers the middle finger.
  2. T4 –> lies at the level of the nipples.
  3. T10 –> Lies over the umbilicus
300
Q

Light touch exam - Steps?

A
  1. With the patient’s eyes closed, touch their skin with a wisp of cotton wool and ask them to say “yes” when it is felt.
  2. The interval between each touch should be irregular and unpredictable!
  3. In practice, a gentle touch with the finger is often used. HOWEVER, this risks testing pressure not light touch sensation. It is also harder to ensure equal force is applied in all areas.
  4. (!) DO NOT, as many do, make tiny stroking movements on the skin - this stimulates hair fibres, and again, is not a test of light touch.
  5. (!) BE AWARE of areas where decr. sensation is expected (foot calluses etc.).
  6. After testing each limb/body area, double check with the patient “did that feel the same all over?” and explore any areas of abnormal sensation more thoroughly before moving on.
301
Q

Sensory inattention - what is it?

A
  1. A subtle but often clinically important sign of parietal lobe dysfunction.
  2. Patient feel stimulus on the affected part - but NOT when there is competition from a stimulus on the opposite side.
302
Q

Sensory inattention - how to exam?

A
  1. Ask the patient to close their eyes and tell you if they feel a touch on their left or right - use any body part - commonly hands and feet as a quick “screen”.
  2. Touch the right hand, then the left hand, then both.
  3. The touches should be repeated randomly to confirm the result.
303
Q

Sensory inattention - example?

A

In a right sided parietal lesion, the patient will feel both left and right stimuli but when BOTH sides are touched, they will not be able to feel the stimulus on the left.

304
Q

Vibration sense - what is used?

A

A 128Hz tuning fork (compare with CN VIII) is used.

305
Q

Vibration sense - How to exam?

A
  1. Ask the patient to close their eyes, tap the tuning fork and place the base on a bony prominence - ask if the patient can feel the vibration.
  2. If “yes”, confirm by taking hold of the tuning fork with your other hand to stop the vibration, after asking the patient to tell you when the vibration ceases.
  3. As always, compare left to right and work in a systematic fashion, testing bony prominences.
306
Q

Vibration sense - bony prominences?

A
  1. Finger tip
  2. Wrist
  3. Elbow
  4. Shoulder
  5. Anterior superior iliac spine
  6. Tibial tuberosity
  7. Metatarsophalangeal joint and toes
307
Q

Proprioception - How to exam?

A
  1. With the patient’s eyes closed and leg relaxed, grasp the distal phalanx of the big toe from the sides.
  2. While stabilizing the rest of the foot, you should move the toe up and down at the joint.
  3. Ask the patient if they can feel any movement - and in which direction.
  4. Flex and extend the joint, stopping at intervals to ask the patient whether the toe is “up” or “down”.
  5. If proprioception is absent, test other joints, working proximally.
308
Q

Proprioception - exam hints?

A
  1. The toe is gripped from the sides - If held incorrectly, pressure on the nail may suggest the toe is pressed down and so on.
  2. Normal proprioception should allow the patient to identify very subtle movements which are barely visible.
309
Q

Romberg sign?

A

A further test of joint position sense. When proprioception is lost in the limbs, patients can often stand and move normally as long as they can see the limb in question.

  1. Ask the patient to stand - and you stand facing them.
  2. Ask the patient to close their eyes.
  3. If there is loss of proprioception, the patient will lose their balancee and fall - if so, catch them with care, asking them to pen their eyes again immediately if they haven’t already done so.
310
Q

Pain (pin-prick) exam - what to use?

A

Use a disposable pin or safety pin - NOT a hypodermic needle as these break the skin - a line of tiny wounds up a patient’s arm or weeping edema up a shin is an infection risk and very embarrassing!

311
Q

Pain (pin-prick) exam?

A
  1. Test as you would for light touch, gently pressing the pin on the skin.
  2. Test each dermatome in a systematic way, mapping out abnormalities.
  3. On each touch, ask the patient to say whether it feels sharp or dull.
  4. Occasionally test the patient’s reliability as a witness with a negative control by using the opposite (blunt) end of the pin.
312
Q

Temperature exam?

A
  1. This is not routinely tested outside specialist clinics.
  2. May be evident from history (accidental burns).
  3. When tested, test tubes or similar vessels containing hot and ice-cold water are used - and each dermatome tested as above.
  4. Remember to ensure that exterior of the tube is dry.
313
Q

Coordination - Upper limbs - Finger-nose test - steps?

A
  1. Ask the patient to touch the end of their nose with their index finger.
  2. Hold your own finger out in front of them - at arm’s reach from the patient - and ask them to then touch the tip of your finger with theirs.
  3. Ask them to move between their nose and your finger.
  4. Look for intention tremor (worse as it approaches the target) and “past-pointing” (missing the target entirely).
  5. The test can be made more difficult by moving the position of your finger each time the patient touches their nose.
314
Q

Coordination/Upper limbs - Rapid alternating movements exam?

A
  1. Should be demonstrated to the patient.
  2. Ask the patient to repeatedly supinate and pronate their forearm keeping the other arm still such that they clap their hands palm-to-palm, then back-to-palm and so on.
  3. Alternatively, ask them to mimic screwing in a light bulb.
315
Q

Coordination/Upper limbs - Dysdiadochokinesis?

A

Slow and clumsy - This is inability to perform rapidly alternating movements.

316
Q

Coordination/Upper limbs - Rebound?

A
  1. From a resting (arms at their side) position, the patient should be asked to quickly abduct their arms and stop suddenly at the horizontal.
  2. In cerebellar disease –> there will be a delay in stopping and the arm will oscillate about the intended final position.
317
Q

Coordination/Upper limbs - Rebound - Alternative test?

A
  1. Pull on the patient’s flexed arms (as if testing elbow flexion power) and suddenly let go.
  2. If lacking coordination, the patient will hit his/herself in the face.
  3. This test does little for doctor-patient trust and rapport and is rarely performed for obvious reasons (!)
318
Q

Coordination/Lower limbs - Heel/shin test?

A
  1. With the patient sitting, legs outstretched, ask them to slide the heel of one foot up and down the shin of the other leg at a moderate pace.
  2. A lack of coordination will manifest as the heel moving side to side about the intended path.
  3. In sensory - as OPPOSED to cerebellar - ataxia (lack of proprioception), patients will perform worse with their eyes closed.
319
Q

Coordination/Lower limbs - Foot tapping?

A
  1. The patient taps your hand with their foot as fast as possible.
  2. The NON-dominant side performs poorly in normal individuals.
320
Q

Median nerve (C6-T1) - Motor?

A

Muscles of the anterior forearm, EXCEPT flexor carpi ulnaris, and LOAF (lateral 2 lumbricals, opponens pollicis, abductor pollicis brevis, flexor pollicis brevis).

321
Q

Median nerve (C6-T1) - Sensory?

A
  1. Thumb
  2. Anterior index and middle fingers
  3. Some of the radial side of the palm
322
Q

Median nerve (C6-T1) - Examining a lesion?

A
  1. Weakness and wasting of the thenar eminence.
  2. With the hand lying flat, palm up, hold your pen above the thumb and ask the patient to move their thumb vertically to touch it (“pen-touching test”) - they will not be able to.
  3. Often power is good here despite symptoms and obvious carpal tunnel syndrome!
323
Q

Median nerve (C6-T1) - Lesions of the nerve at the cubital fossa - exam?

A

Perform Ochsner’s Clasping Test for weakness of flexor digitorum superficialis - ask the patient to clasp their hands together.
If a lesion is present, the index finger will fail to flex!

324
Q

Ulnar nerve (C8-T1) - Motor?

A

All the small muscles of the hand EXCEPT LOAF + Flexor carpi ulnaris.

325
Q

Ulnar nerve (C8-T1) - Sensory?

A
  1. Ulnar side of the hand.

2. Little finger and half of ring finger.

326
Q

Ulnar nerve (C8-T1) - Exam a lesion?

A

Hard to test. There may be visible wasting of the small muscles of the hand with clawing of the fingers –> extension at the phalangeo-metacarpal joints and flexion at the interphalangeal joints.

327
Q

Ulnar nerve (C8-T1) - Froment’s sign?

A

Ask the patient to grasp a piece of paper between their thumb and forefinger.
Alternatively, ask them to make a fist.
–> Thumb is unable to adduct so will flex instead.

328
Q

Radial nerve (C5-C8) - Motor?

A
  1. Triceps
  2. Brachioradialis
  3. Extensors of the hand
329
Q

Radial nerve (C5-C8) - Sensory?

A

A small area over the anatomical snuff box - hard to test.

330
Q

Radial nerve (C5-C8) - Exam a lesion?

A
  1. Look for wrist drop.
  2. If not obvious, ask the patient to flex at the elbow, pronate the forearm and extend the wrist (you may need to demonstrate).
  3. Wrist weakness will become clear.
331
Q

Lateral cutaneous nerve of the thigh (L2-L3) - Motor?

A

NONE

332
Q

Lateral cutaneous nerve of the thigh (L2-L3) - Sensory?

A

The lateral aspect of the thigh.

333
Q

Lateral cutaneous nerve of the thigh (L2-L3) - Exam a lesion?

A

There may be some sensory loss as indicated but, in practice, this is very hard to test.

334
Q

Common peroneal nerve (L4-S2) - Motor?

A

Anterior and lateral compartments of the leg.

335
Q

Common peroneal nerve (L4-S2) - Sensory?

A

The dorsum of the foot and the anterior aspect of the leg.

336
Q

Common peroneal nerve (L4-S2) - Exam a lesion?

A
  1. “Foot-drop” with corresponding gait. Weakness of foot dorsiflexion and eversion. Preserved inversion.
  2. In an L5 lesion, there will be a similar deficit but will also display a weakness of inversion, hip abduction and knee flexion.
337
Q

Femoral nerve (L2-L4) - Motor?

A

Quadriceps femoris.

338
Q

Femoral nerve (L2-L4) - Sensory?

A

Medial aspect of thigh and leg.

339
Q

Femoral nerve (L2-L4) - Examining a lesion?

A
  1. Weakness of knee extension is only slightly affected - hip adduction is preserved.
  2. Stretch: With the patient lying prone, abduct the hip, flex the knee and plantar-flex the foot.
  3. The stretch is positive if pain is felt in the thigh/inguinal region.
340
Q

Sciatic nerve (L4-S3) - Motor?

A

All the muscles below the knee and some hamstrings.

341
Q

Sciatic nerve (L4-S3) - Sensory?

A

Posterior thigh, ankle and foot.

342
Q

Sciatic nerve (L4-S3) - Examining a lesion?

A
  1. Foot drop and weak knee flexion.
  2. Knee jerk reflex is preserved but ankle jerk and plantar response are absent.
  3. Stretch test: with the patient lying supine, hold the ankle and lift the leg, straight to 90 degrees. Once there, dorsiflex the foot.
  4. If positive, pain will be felt at the back of the thigh.
343
Q

Tinel’s sign?

A

A test for nerve compression. Commonly used for carpal tunnel syndrome.

  1. Percuss the nerve over the site of possible compression - at the wrist, gently tap centrally near the flexor palmaris tendon.
  2. If the nerve is compressed, the patient will experience tingling in the distribution of the nerve on each tap.
344
Q

Gait - How to exam?

A

Ask the patient to walk a few meters, turn and walk back to you.
Note especially:
1. Use of walking aids.
2. Symmetry
3. Size of paces
4. Lateral distance between the feet
5. How high the feet and knees are lifted.
6. Bony deformities
7. Disturbance of normal gait by abnormal movements
–> You may want to consider asking the patient to:
1. Walk on tip-toes –> Inability = S1 or gastrocnemius lesion.
2. Walk on their heels –> Inability = L4/L5 lesion - foot drop.

345
Q

Hemiplegia?

A

One side will be obviously weaker than the other with the patient tilting pelvis to lift the weak leg which may swing out to the side.
Gait may be unsafe without the use of walking aid.

346
Q

“Scissoring”?

A

If both legs are spastic (cerebral palsy, MS), toes drag on floor, trunk sways from side-to-side, and legs cross over on each step.

347
Q

Parkinsonism?

A
  1. Flexed posture with small, shuffling steps.
  2. No or little arm-swing.
  3. Difficulty starting, stopping and turning.
  4. Gait seems hurried (“festinant”) as legs attempt to prevent body falling forwards.
348
Q

Cerebellar ataxia?

A
  1. Broad based (legs wide) gait with lumbering body movements and variable distance between steps.
  2. Difficulty turning - be there to catch them!
349
Q

Sensory ataxia?

A
  1. Loss of proprioception.
  2. Patient requires more sensory input to be sure of leg position so lifts legs high (high-stepping) and stamps feet down with a wide-based gait - may also watch legs as they walk.
  3. Romberg’s sign positive.
350
Q

Waddling?

A
  1. Weakness of proximal lower limb muscles.
    2 Patient fails to tilt pelvis as normal so incr. rotation to compensate - also at the shoulders.
  2. May also see incr. lumbar lordosis.
351
Q

Foot drop?

A
  1. L4-L5 lesion, sciatic, or common peroneal nerves.
  2. Failure to dorsiflex the foot leads to a “high-stepping” gait with incr. flexion at the hip and knee.
  3. If bilateral, may indicate peripheral neuropathy.
352
Q

Apraxis?

A
  1. Usually frontal lobe pathology such as normal pressure hydrocephalus or cerebrovascular disease.
  2. Problems with gait even if all other movements may be normal.
  3. Patient may appear frozen to the spot and unable to initiate walking.
  4. Movements are disjointed once walking.
353
Q

Marche a petits pas?

A

Diffuse cortical dysfunction - Upright posture, small steps with a normal arm-swing.

354
Q

Painful gait?

A

The cause will normally be obvious from the history. The patient limps with an asymmetrical gait due to painful movement.

355
Q

Functional gait (also known as hysterical)?

A
  1. Gait problems will be variable and inconsistent, often with bizarre and elaborate consequences.
  2. May fall without causing injury.
  3. Often worse when watched.
356
Q

Neck stiffness - etiology?

A

A number of conditions provoking painful extensor muscle spasm:

  1. Bacterial and viral meningitis
  2. Subarachnoid hemorrhage
  3. Parkinsonism
  4. Raised intracranial pressure
  5. Cervical spondylosis
  6. Cervical lymphadenopathy
  7. Pharyngitis
357
Q

Testing stiffness - steps?

A
  1. Lie the patient flat
  2. Taking their head in your hands, gently rotate it to the sides in a “no” movement, feeling for stiffness.
  3. Lift the head off the bed and watch the hips and knees - the chin should easily touch the chest.
358
Q

Brudzinski’s sign?

A

When the head is flexed by the examiner, the patient briefly flexes at the hips and knees - a test for meningeal irritation.

359
Q

Kernig sign?

A
  1. Further test for meningeal irritation.
  2. With the patient lying flat, flex their hip and knee, holding the weight of the leg yourself.
  3. With the hip flexed to 90 degrees, extend the knee joint so as to point the leg at the ceiling.
  4. If positive, there will be resistance to leg straightening (caused by hamstring spasm as a result of inflammation around the lumbar spinal roots) and pain felt at the back of the neck.
360
Q

Lhermitte’s phenomenon?

A
  1. A test for an intrinsic lesion in the cervical cord (not meningeal irritation).
  2. When the neck is flexed as above, the patient feel an electric shock-like sensation down the centre of their back.
361
Q

UMN lesions - defined?

A

Damage ABOVE the level of the anterior horn cell - anywhere from the spinal cord to the primary motor cortex.

362
Q

UMN lesions - features?

A
  1. No muscle wasting (although will have disuse atrophy in long-term weakness).
  2. Incr. tone –> Spasticity (clasp-knife) due to stretch reflex hypersensitivity.
  3. Typical pattern of weakness is termed “pyramidal”:
    - Upper limbs: weak abductors and extensors.
    - Lower limbs: weak adductors and flexors.
  4. Incr. tendon reflexes and clonus - Up-going plantar response.
363
Q

LMN lesions - Features?

A
  1. Muscle wasting. Fasciculations.
  2. Decr. tone.
  3. Flaccid paralysis
  4. Decr. tendon reflexes. Plantar response may be down-going or absent.
364
Q

Monoplegia/Hemiplegia/Paraplegia/Quadriplegia?

A

Mono –> One limb is affected.
Hemi –> One side of the body (Left or right).
Para –> Both LOWER limbs affected.
Quadriplegia –> All 4 limbs affected.

365
Q

Motor neuron disease (MND) - Features?

A

Damage to anterior horn cells, medulla, spinal tracts:

  1. UMN/LMN pattern of weakness.
  2. Fasciculations almost always present.
  3. Reflexes normal or incr. until later in the disease.
  4. Plantar response is up-going.
  5. External ocular muscles almost never involved.
  6. No sensory disturbance (distinguishing the presentation from a poluneuropathy).
366
Q

Parkinsonism - General features?

A
  1. Pattern of symptoms comprising an akinetic/rigid syndrome.
  2. Number of causes including drug-induced and other intracranial pathologies.
  3. Diagnosis is often inaccurate and there NO SINGLE TEST.
  4. Triad of: Resting tremor + Bradykinesia + Rigidity.
367
Q

Parkinsonism - Face?

A
  1. Mask-like and expressionless facies.
  2. Little blinking
  3. Positive glabellar tap reflex.
368
Q

Parkinsonism - Gait?

A
  1. Flexed posture with decr. arm swing.
  2. Gait is “festinant” meaning “hurried” often in small, shuffling steps with feet barely lifted off ground.
  3. Slow to start and difficulty stopping.
369
Q

Parkinsonism - Tone?

A

Incr. tone with cogwheel or “lead-pipe” rigidity.

370
Q

Parkinsonism - Tremor?

A

Pill-rolling flexion at the thumb and forefinger at 4-8Hz.

371
Q

Parkinsonism - Speech?

A

Extrapyramidal dysarthria, soft, quiet, and hesitant speech.

You may have to wait some time for the answer to a question!

372
Q

Parkinsonism - Writing?

A

Writing is small and neat “micrographia”.

373
Q

Akathisia?

A

Motor restlessness with a feeling of muscle quivering and an inability to remain in a sitting position.

374
Q

Athetosis?

A

Slow, writhing involuntary movements often with flexion, extension, pronation, and supination of the fingers and wrists.

375
Q

Blepharospasm?

A

Intermittent spasm of muscles around the eyes.

376
Q

Chorea?

A
  1. Non-rhythmical, dance-like, spasmodic movements of the limbs or face.
  2. Appear pseudo-purposeful (the patient often hides the condition by turning a spasm into a voluntary movement - eg the arm suddenly lifts up the patient pretends they were adjusting their hair).
377
Q

Dyskinesia?

A

Repetitive, automatic movements that stop only during sleep.

378
Q

Tardive dyskinesia?

A

Dyskinetic movements often of the face (lip-smacking, twisting of the mouth).
–> Often a side effect of neuroleptic therapy.

379
Q

Dystonia?

A

Markedly increased tone often with spasms causing uncomfortable-looking postures.

380
Q

Hemiballismus?

A

Violent involuntary flinging movements of the limbs on one side - rather like severe chorea.

381
Q

Myoclonus?

A

Brief, shock-like movement of a muscle or muscle-group.

382
Q

Pseudoathetosis?

A
  1. Writhing limb movements (often finger/arm) much like athetosis but caused by a loss of proprioception.
  2. The arm returns to the normal position when the patient notices it straying.
383
Q

Myokymia?

A

Continuous quivering and rippling movements of muscles at rest like a “bag of worms”.
Facial myokymia: especially near the eyes.

384
Q

Tic?

A
  1. Repetitive, active, habitual, purposeful contractions causing stereotyped actions.
  2. Can be suppressed for brief periods with effort.
385
Q

Titubation?

A

Rhythmical contraction of the head. May be either “yes-yes” or “no-no” movements.

386
Q

Tremor?

A

Repetitive, alternating movements, usually involuntary.

387
Q

Hemisection of the cord?

A

Also known as Brown-Sequard syndrome:

  1. Motor –> Below the level of the lesion, UMN pattern of weakness on IPSILATERAL side.
  2. Sensory –> Below the level of the lesion:
    a. CONTRALATERAL loss of pain and temperature.
    b. IPSILATERAL loss of light-touch, vibration sense, and proprioception.
    c. Light touch may remain intact as some fibres travel in the spinothalamic tract.
388
Q

Posterior column loss?

A

Loss of vibration sense and proprioception on BOTH sides below the level of the lesion.

389
Q

Subacute combined degeneration of the cord?

A

Also known as posterolateral column syndrome - often due to B12 def.

  1. Loss of vibration sense and proprioception on both sides below the level of the lesion.
  2. UMN weakness in lower limbs, ABSENT ankle reflexes.
    • Peripheral sensory neuropathy, optic atrophy and dementia.
390
Q

Anterior spinal artery occlusion?

A
  1. Loss of pin-prick and temperature sensation below the lesion.
  2. INTACT light-touch, vibration sense, and proprioception.
391
Q

Central lesions - features?

A
  1. Loss of pain and temperature sensation over the neck, shoulders, and arms in a “cape” distribution.
  2. Intact vibration sense, proprioception, and light touch.
  3. Atrophy and areflexia in the arms.
  4. UMN weakness in the lower limbs.
  5. Look also for scoliosis due to weakness of paravertebral muscles.
392
Q

Cerebellar lesions - General signs?

A
  1. Signs are IPSILATERAL.
  2. Nystagmus
  3. Speech is staccato, scanning.
  4. Decr. tone, drift and tremor in limbs (upper especially)
  5. Finger-nose testing may reveal intention tremor and past-pointing.
  6. Dysdiadochokinesis
  7. Rebound
  8. Pendular jerks - best seen in the knee. Test the tendon reflex at the knee as normal. If “pendular”, the extensor response will continue to several beats.
  9. Poor sitting balance.
  10. Ataxic gait.
393
Q

Disturbance of higher functions - Parietal lobe?

A
  1. Sensory and visual inattention.
  2. Visual field defects
  3. Agnosias (lack of sensory perceptual abilities)
  4. Apraxias - inability to perform movements or use objects correctly.
  5. Gerstmann’s syndrome
394
Q

Agnosias - Mention some?

A
  1. Hemi-neglect - patient ignores on side of their body.
  2. Asomatagnosia - patient fails to recognize own body part.
  3. Anosagnosia - patient is unaware of neurological deficits.
  4. Finger agnosia - patient is unable to show you different fingers when requested (eg show me your index finger).
  5. Astereognosis - Inability to recognize an object by touch alone.
  6. Agraphaesthesia - inability to recognize letters or numbers when traced on the back of the hand.
  7. Prosopagnosia - Inability to recognize faces (test with family members or famous faces from a nearby magazine).
395
Q

Apraxias - Mention some?

A
  1. Ideational apraxia
  2. Ideomotor apraxia
  3. Dressing apraxia
396
Q

Ideational apraxia?

A

Unable to perform task but understands what is required.

397
Q

Ideomotor apraxia?

A

Performs task but makes mistakes (puts tea into kettle and pours milk into cup).

398
Q

Dressing apraxia?

A

Inability to dress correctly - test with a dressing gown.

One of a number of apraxias named after the action tested.

399
Q

Gerstmann syndrome?

A
  1. Right-left dissociation.
  2. Finger agnosia
  3. Dysgraphia
  4. Dyscalculia (test with serial 7s).
400
Q

Disturbance of higher functions - Temporal lobe?

A

Memory loss - confabulation (invented stories and details).

401
Q

Disturbance of higher function - Frontal lobe?

A
  1. Primitive reflexes
  2. Concrete thinking (unable to explain proverbs - eg ask to explain what “a bird in the hand is worth two in the bush” means).
  3. Loss of smell sensation.
  4. Gait apraxia.
402
Q

Myopathies - general features?

A
  1. Muscle disease causes a weakness similar to that of LMN lesions with NO SENSORY LOSS.
  2. Tendon reflexes are reduced or absent.
403
Q

Myotonias - Features?

A

Characterized by continued, involuntary muscle contraction after voluntary effort has ceased.

404
Q

Myotonic dystrophy - defect?

A

A defect of skeletal muscle Cl channels caused by a trinucleotide repeat, usually.
Becomes evident age 20-50.

405
Q

Myotonic dystrophy - Features?

A
  1. Distal limb weakness.
  2. Weak sternomastoids - evident by weakness of neck flexion with normal power on neck extension.
  3. Weak facial muscles - expressionless face.
  4. Test by shaking the patient’s hand - they may be unable to let go!
406
Q

Myotonic dystrophy - Associations?

A
  1. Frontal baldness
  2. Cataracts - look for thick glasses
  3. Mild intellectual impairment
  4. Cardiomyopathy
  5. Hypogonadism
  6. Glucose intolerance
407
Q

Percussion myotonia?

A

Tap the patient’s thenar eminence, this will cause contracion and very slow relaxation of abductor pollicis brevis.

408
Q

Myasthenia gravis - general?

A

Autoimmune disease with antibodies against ACh receptors.

409
Q

Myasthenia gravis - Signs?

A
  1. Complex palsies - including extraocular muscles.
  2. Weakness is proximal and often includes the eyelids (ptosis) and muscles of mastication.
  3. Weakness increases with USE. Patients report incr. severity of symptoms at the end of the day.
  4. In the early stages, will feel tired as they expend extra energy in performing routine tasks.
  5. Friends may notice ptosis.
410
Q

Myasthenia gravis - test?

A

Test for fatiguability:

  1. Ask the patient to look to the ceiling and hold the position. Watch for ptosis.
  2. Ask the patient to hold their arms above their head - or out to the sides - watch for incr. weakness.
411
Q

Tension headache - features?

A
  1. Bilateral - frontal, temporal.
  2. Sensation of tightness radiating to neck and shoulders.
  3. Can last for days.
  4. No associated symptoms.
412
Q

Subarachnoid hemorrhage - features?

A
  1. Sudden, dramatic onset “like being hit with a brick”.
  2. Occipital initially - may become generalized.
  3. Associated with neck stiffness and sometimes photophobia.
413
Q

Sinusitis - features?

A
  1. Frontal, felt behind the eyes or over the cheeks.
  2. Ethmoid sinusitis is felt deep behind the nose.
  3. Overlying skin may be tender.
  4. Worse on bending forwards.
  5. Lasts 1-2 weeks. Associated with coryza.
414
Q

Temporal (giant cell) arteritis associated headache?

A
  1. Diffuse, spreading from the temple - unilateral.
  2. Tender overlying temporal artery (painful brushing hair).
  3. Jaw claudication while eating
  4. Blurred vision - can lead to loss of vision if severe and untreated.
415
Q

Meningitis - Headache?

A
  1. Generalized
  2. Associated with neck stiffness and signs of meningism.
  3. Nausea, vomiting, photophobia
  4. Pruritic rash is caused by septicemia, not meningitis per se
416
Q

Cluster headache?

A
  1. Rapid onset, usually felt over one eye.
  2. Associated with a blood-shot, watering eye, and facial flushing.
  3. May also have rhinorrhea (runny nose).
  4. Last for a few weeks at a time.
417
Q

Raised intracranial pressure - headache?

A
  1. Generalized headache, worse when lying down, straining, coughing, on exertion or in the morning.
  2. Headache may wake the patient in the early hours.
  3. May be associated with drowsiness, vomiting, and focal neurology.
418
Q

Migraine - features?

A
  1. Unilateral - rarely crossed the midline.
  2. Throbbing/pounding headache.
  3. Associated with photophobia, nausea, vomiting, and neck stiffness.
  4. May have preceding aura.
419
Q

The unconscious patient - History?

A
  1. Eye-witness account? State of clothing - loss of continence?
  2. Look for alert necklace/bracelet. Look in the wallet, purse etc.
420
Q

The unconscious patient - exam - ABC?

A
  1. Is the airway patent? Should the patient be in the recovery position?
  2. Measure RR, note pattern of breathing. Is O2 needed?
  3. Cyanosis? Feel pulse. Listen to chest. Measure HR, BP.
421
Q

The unconscious patient - Skin?

A

Look for injury, petechial hemorrhage, evidence of IVDA.

422
Q

The unconscious patient - Movements/posture?

A
  1. Watch! Is the patient still or moving? All 4 limbs moving equally?
  2. Any abnormal movements - fitting, myoclonic jerks?
  3. Test tone and compare both sides.
  4. Squeeze the nail bed to test the response to pain (all 4 limbs).
423
Q

Decorticate posture is?

A

Lesion ABOVE the brainstem:

  1. Flexion + Internal rotation of the arms.
  2. Extension of the lower limbs.
424
Q

Decerebrate posture is?

A

Lesion in the MIDBRAIN:

  1. Extension at the elbow
  2. Pronation of the forearm
  3. Extension at the wrist
  4. Extension of the lower limbs
425
Q

The unconscious patient - Consciousness?

A
  1. Attempt to wake the patient by sound.
  2. Ask their name.
  3. If responsive, are they able to articulate properly?
  4. Note the best response.
  5. Be aware of possible dys- or aphasia which may cause an inappropriate response in an otherwise healthy individual.
  6. Score level of consciousness according to GCS.
426
Q

The unconscious patient - Neck?

A
  1. Do NOT examine if there may have been trauma.

2. Test for meningeal irritation - these signs decr. as coma deepens.

427
Q

The unconscious patient - Head?

A

Inspect for signs of trauma and facial weakness. Test pain sense.

428
Q

Battle’s sign?

A

Bruising behind the ear = base of skull fracture.

429
Q

The unconcious patient - Ear/nose?

A
  1. Look for CSF leakage or bleeding.
  2. Test any clear fluid for glucose (positive result = CSF).
  3. Inspect eardrums.
430
Q

The unconscious patient - Tongue/Mouth?

A
  1. Look for cuts on the tongue (seizures), corrosive material around the mouth.
  2. Smell breath for alcohol or ketosis.
  3. Test the gag reflex - absent in brainstem disease or deep coma.
431
Q

The unconscious patient - Eyes?

A
  1. Pupils - measure size in mm. Are they equal?
  2. Test direct and consensual light responses.
  3. Pupils incr. with atropine, TCAs, amphetamine.
  4. Pupils decr. with morphine, metabolic coma.
  5. Test corneal reflex.
  6. Fundi –> look especially for papilloedema and retinopathy.
432
Q

The unconscious patient - Eyes - Doll’s head manoeuvre?

A
  1. Take the patient’s head in your hands and turn in from side-to-side.
  2. The eyes should move to stay fixed on an object - indicates INTACT BRAINSTEM.
433
Q

The unconscious patient - Rest of the body?

A 
A brief but thorough exam.
Look especially for:
1. Trauma
2. Fractures
3. Signs of liver disease
4. Added heart sounds
434
Q

The unconscious patient - other bedside tests?

A
  1. Test urine
  2. Capillary glucose
  3. Temperature
435
Q

Glasgow Coma Scale (GCS)?

A

Objective score of consciousness.
A. Eye opening (max 4 points)
4 - Spontaneously open
3 - Open to (any) verbal stimulus
2 - Open in response to painful stimulus
1 - No eye opening at all
B. Best verbal response (max 5 points)
5 - Normal
4 - Conversing but disoriented and confused
3 - Inappropriate words (random words, no conversation)
2 - Incomprehensible sounds (moaning etc)
1 - No speech at all
C. Best motor response (max 6 points)
6 - Obeying commands (raise your hand)
5 - Localizing to pain (moves hand towards site of stimulus)
4 - Withdraws to pain (pulls hand away from stimulus)
3 - Abnormal flexion to pain (decorticate posture)
2 - Abnormal extension to pain (decerebrate posture)
1 - No response at all

436
Q

Dizziness - what should be done?

A

Narrow the exact meaning down without appearing aggressive or disbelieving. This term is used by different people to describe rather different things.

Internal Medicine (107 decks)

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