Block 5 - Neurology Flashcards

Question

Cranial Nerve Exam - Introduction, Exposure and Positioning?

Answer 1

**Cranial Nerve Exam - Introduction ** 1. Introduces self 2. Washes hands 3. Explains examination & gains verbal consent 4. Confirms Name & Age 5. Shakes hand, assessing handedness **Exposure and Positioning** Sitting upright if well, with legs over side of bed if possible "Hi, my name is Kitty, I'm a second year medical student from the University of Notre Dame. I've been asked to come and examine your cranial nerves. These are the nerves in your head and neck that control our senses like seeing, hearing, taste and swallowing. Is that ok with you? The exam shouldn't take to long and if at any point you feel uncomfortable we can stop. Before we get started please can I confirm your Name & Age? Is there anything I can get you before we start to make you more comfortable? Perfect, please can you hop up onto the bed, facing me with your legs hanging over the edge. Thank you. As we go along I will just relay my findings to the doctor but if you need to please feel free to interrupt."

Answer 2

**Cranial Nerve Exam - General Inspection** 1. General Condition – well/unwell? 2. Septic/rash? 3. Conscious level (GCS score if pt obtunded)? 4. Facial asymmetry? 5. Facial/neck masses? 6. Face/neck surgical scars?

Answer 3

**Cranial Nerve Exam - CNI: Olfactory** "We will start with the first cranial nerve, the olfactory nerve. Have you noticed any changes in your sense of smell recently?" If yes - coffee/orange test

Answer 4

**Cranial Nerve Exam - CNII: Optic** 1. **Visual acuity **– Snellen chart stand: 6ms away and read lines one eye at time with glasses 2. **Visual fields** – direct confrontation, testing each quadrant and central vision in each eye. - Cover same side eye to the patient and 4 times bring your finger out and into the visual field. "I'm going to cover the same eye as you and I want you to tell me when you can see my red pin." 3. **Fundi** (ophthalmoscopy) -right eye examiner into right eye patient and left into left - raised ICP? Hypertensive retinopathy?

Answer 5

**Cranial Nerve Exam = III - Oculomotor, IV - Trochlear, VI - Abducens** 1. **Pupils** – size and symmetry, direct and consensual light reflex. 2. **Accommodation** – move finger from a distance towards patient. Pupils constrict and converge. 3. **Eye movements** – full range, conjugate. Move hat pin/pen in H shape ask patient to report diplopia. Image separation is maximal where affected muscles action is purest. 4. **Ptosis**.

Answer 6

**Cranial Nerve Exam - V: Trigeminal ** 1. **Facial sensation** – ophthalmic, maxillary, mandibular divisions 2. **Masseter and temporal muscles** – Clench teeth, palpate masseters. 3. **Masseter reflex (Jaw jerk)**. 4. Corneal reflex (only test on real patients with a genuine possibility of abnormality)

Answer 7

**Cranial Nerve Exam - CNVII: Facial** 1. Facial droop 2. Test muscle power – show teeth/smile, close eyes tight, raise eyebrows to ceiling. (UMN lesion - forehead is spared)

Answer 8

**Cranial Nerve Exam - CNVIII: Acoustic** 1. **Whisper in each ear** = 'I'm going to whisper a number in your ear and I want you to tell me what it is. 99 and 33" 2. **Rub fingers moving away from ear until pt cannot hear it **= "Let me know when you can no longer hear me rubbing my fingers." 3. **Rinnes Test** = Tuning fork (512Hz) on mastoid bone until they can no longer hear then infront of ear until it stops 4. **Webers tests** = Place tuning fork (512Hz) on centre of forehead. If it's heard louder on one side - that is the side with conductive hearing loss. 5. If complains of vertigo – **Hallpikes** manoeuvre

Answer 9

**Cranial Nerve Exam - IX = Glossopharyngeal & X = Vagus** 1. Open mouth inspect uvula, ask patient to say ‘Ah’ - uvula deviates towards side of lesion 2. Gag reflex/touch sides of pharynx, ask if sensation present 3. Quality of voice 4. Ask patient to cough. 5. Swallow sip of water

Answer 10

**Cranial Nerve Exam - CNXI: Accessory** 1. **Trapezius** - Shrug shoulders and don't let me push down 2. **Sternocleidomastoid** - turn head against resistance

Answer 11

**Cranial Nerve Exam - CNXII: Hypoglossal ** 1. Examine tongue at rest 2. Stick out tongue move side to side - Tongue pushed towards side of lesion

Answer 12

**Cranial Nerve Exam - Other** 1. Perform Peripheral nervous system examination. 2. Movement, Higher functioning 3. Mental state examination 4. Test for neck stiffness - Kernigs and Brudzinski if present. 5. Examine for rash. **KERNIGS** – with patient lying flat perform passive hip flexion with knee flexed. Then extend the knee. This will elicit pain in meningeal irritation **BRUDZINSKI** – patient lying flat, place one hand behind head and other on chest to restrain patients thorax. Lift patient’s head off bed. Positive when patient’s legs flex

Answer 13

DASHING – Dyskinesia, Ataxia, Speech, Hypotonia, Intention tremor, Nystagmus, Gait.

Answer 14

**Cerebellar Exam Protocol** 1. Introduction 2. Exposure and Positioning 3. Inspection 4. Eyes 5. Speech 6. Arms 7. Trunk 8. Legs 9. Gait 10. Other

Answer 15

**Cerebellar Exam Protocol - Introduction & Exposure and Positioning** "Hi, my name is Kitty and i'm a second year medical student from the university of Notre dame. I've been asked to come and examine you for any cerebellar problems. The cerebellum is the area of the brain that controls things like coordination, how our eyes move and how we speak. So i'll be testing to make sure they are all normal. It shouldn't take long and if you're uncomfortable at any point we can stop. Does that all sound ok? Before we get started please can I confirm your name and age? Great thank you for that. I'll just get you to sit up on the bed facing me with your legs hanging over the edge if thats ok?"

Answer 16

**Cerebellar Exam Protocol - General Inspection** 1. General Condition: well/unwell 2. Walking aids 3. Obvious limb weakness 4. Tremor 5. Facial asymmetry

Answer 17

**Cerebellar Exam Protocol - Eyes** 1. Nystagmus – ‘follow my finger with your eyes’ move finger in horizontal and vertical planes. (Nystagmus will be elicited in everyone at extremes of lateral gaze). Direction of fast movement is side of lesion

Answer 18

**Cerebellar Exam Protocol - Speech** 1. Dysarthric speech – ‘West register street’, ‘baby hippopotamus’ usually said to have abnormal scanning speech not slurred

Answer 19

**Cerebellar Exam Protocol - Arms** 1. **Drift** – Raise arms out in front with palms facing up and eyes closed, look for arm drift due to hypotonia which only occurs in very acute cerebellar lesions. Examine for tone in the usual way when appropriate 2. **Intention tremor and past pointing** – ‘Move index finger of right hand from your nose to my finger as quickly and as accurately as you can’ check both sides 3. **Dysdiadochokinesis** – Ask patient to turn hand over on palm of opposite hand as fast as possible. Check both sides 4. **Rebound** - Raise arms rapidly from sides then stop – inability to stop (Drift and rebound will also occur in proprioceptive lesions) *(Ipsilateral cerebellar lesion, unless bilateral disease)*

Answer 20

**Cerebellar Exam Protocol - Trunk** 1. Ask to sit unsupported on side of bed (if previously lying down) note imbalance 2. Check knee reflexes whilst sat up (pendular)

Answer 21

**Cerebellar Exam Protocol - Legs** 1. Check tone 2. ‘Run heel of left foot down right shin’ check both sides 3. Toe to finger tapping

Answer 22

**Cerebellar Exam Protocol - Gait? (3)** 1. **Assess gait** - Midline vermal lesion will cause ataxia. - If a unilateral cerebellar hemisphere lesion patient will stagger to side of lesion. - Unsteady with a wide based gait 2. **Romberg**’s to differentiate from proprioceptive problem. Stand close to patient to catch them if they start to fall - Romberg's test is positive in conditions causing sensory ataxia such as: Vitamin deficiencies such as Vitamin B. Conditions affecting the dorsal columns of the spinal cord, such as tabes dorsalis (neurosyphilis)

Answer 23

**Cerebellar Exam Protocol - Other** 1. Cranial and Peripheral nerve examination 2. Vascular exam if suspect CVA 3. Peripheral signs of malignancy 4. At completion of respiratory exam

Answer 24

**Peripheral Nervous System Examination Protocol - Upper limb** 1. Introduction 2. Exposure & Positioning 3. General Inspection 4. Pronator drift + rebound 5. Tone - wrist, hand, elbow 6. Power - shoulder, elbow, wrist, fingers 7. Reflexes - biceps, triceps, supinator, finger jerk 8. Coordination - finger nose & dysdiadochokinesis 9. Sensation - temperature, light touch, vibration, proprioception 10. Functional - button up shirt, write with a pen 11. Additional

Answer 25

**Peripheral Nervous System Examination Protocol - Introduction & Exposure and Positioning** 1. Introduces self 2. Washes hands 3. Explains examination and gains consent 4. Confirms name & age 5. Shakes hand - myoclonus/weakness "Hi, my name is Kitty, I'm a second year medical student. I've been asked to come and examine your upper limbs for any problems. This will involve me having a look at how they move and checking your reflexes and sensation. Does this all sound ok to you? Before we get started please can I confirm your name and age? Are you in any pain at all? Please can you sit on the bed with your legs hanging over the end? I will need to see your arms if thats ok to remove your shirt?"

Answer 26

**Peripheral Nervous System Examination Protocol - Inspection** 1. General Condition: well/unwell 2. Conscious level 3. Rash 4. Cachectic 5. Walking aid 6. Muscle wasting 7. Fasciculation 8. Tremor 9. Scars

Answer 27

**Peripheral Nervous System Examination Protocol - Upper Limb** **Tone** 1. flexion/extension at wrist 2. supinate/pronate hand 3. flexion/extension at elbow

Answer 28

**Peripheral Nervous System Examination Protocol - Upper Limb** **Power**: 1. Shoulder abduction & adduction 2. Elbow flexion, extension 3. Wrist flexion, extension 4. Fingers – flexion, extension, abduction, thumb abduction

Answer 29

**Peripheral Nervous System Examination Protocol - Upper Limb - Reflexes** 1. Biceps (C5,C6) - one finger on antecubital fossa 2. Triceps (C6,C7) - arm across patient 3. Supinator (C5,C6) - 2 fingers over distal radius 4. Finger jerk (C8) - loosely grip the patients fingers in yours and tap your own fingers

Answer 30

**Upper Limb Neuro Exam** **Co-ordination** 1. Finger nose - remember pt must reach 2. Dysdiadochokinesis - hand pronate/supinate with speed **Sensation** 1. Spinothalamic tracts – *pain*, temperature, light touch with cotton wool 2. Posterior columns – vibration (128 Hz on distal finger joint, eyes closed until it stops) and proprioception (eyes open, show pt fingers up and down then eyes closed and ask if the finger is up or down) Get patient to close eyes when testing light touch - place on chest first then on the upper arm (C5), outside forearm (C6), index finger (C7), inside forearm (C8), inside upper arm (T1).

Answer 31

**Upper Limb Neuro Exam - Closing** 1. Ask patient to put shirt on & button up 2. Thank patient 3. Let the examiner know you have finished by saying: "In summary, pt's name presented with *upper limb weakness bilaterally* and on examination tone, power, reflexes coordination and sensation (both posterior and spinothalamic tracts were intact."

Answer 32

**Peripheral Nervous System Examination Protocol - Lower Limb** 1. Inspections 2. Tone - log roll & leg drop & ankle clonus 3. Power - Hip (4), Knee (2), ankle (2), tarsal joint (2) 4. Reflexes - knee, ankle, plantar (babinski) 5. Coordination - heel/shin & foot tapping 6. Sensation - pain, temp, light touch, vibration & proprioception 7. *Saddle sensation/anal tone as needed* 8. Gait - walk, turn around quickly, heel-toe, tippy-toes, heel walk, squat 9. Romberg's

Answer 33

**Locomotion (Parkinsonism) Examination Protocol** 1. Introduction = 5 2. Exposure and positioning 3. General inspection = 4 4. Gait = 7 5. Face = 3 6. Upper Limbs = 5 7. Speech = 3 8. Handwriting = 1 9. Parkinson's Plus = 1 10. Other = 3

Answer 34

**Locomotion (Parkinsonism) Examination - Introduction, Exposure and positioning** 1. Introduces self 2. Washes hands 3. Explains exam & gains consent 4. Shakes patient's hand 5. Confirms name and age "Hi, my name is Kitty I'm one of the medical students. I've been asked to come and examine you for any problems you might have with locomotion or Parkinsons. This will involve me having a look at how you walk and move around, your eye movements, your speech and your hand movements. Does this all sounds ok to you?" "Great, before we get started please can I confirm your name and age? And are you in any pain at all? Is there anything I can get to make you more comfortable? Are you able to walk safely without an aid? Do you feel well enough to sit up?

Answer 35

**Locomotion (Parkinsonism) Examination - General Inspection** 1. General Condition: well/unwell. 2. Limb weakness/paralysis. 3. Tremor or other extra movements. 4. Walking aids

Answer 36

**Locomotion (Parkinsonism) Examination - Gait** 1) Ask to walk in straight line, turn quickly and walk back again and stop - looking for: 1. Shuffling 2. Festination 3. Increased number of steps on turning 4. Imbalance 5. Drift 2) Walk heel to toe if possible 3) Explain that you would perform Retropulsion – pull pt backwards by shoulders whilst standing behind to catch them if they fall. Generally would describe to examiner rather than do 4) In a clinical setting “timed get up and go”

Answer 37

**Locomotion (Parkinsonism) Examination - Face** 1. Lack of facial expression 2. Head titubation 3. Glabellar tap (tap on forehead with finger out of vision of patient. Positive when ongoing blink response to tapping)

Answer 38

**Locomotion (Parkinsonism) Examination - Upper Limbs** 1. Observe hands in lap 2. Tremor – ‘pill rolling’? Resting? 3. Tremor - Increases with distraction? (Ask pt to do serial 7’s) postural? 4. Tremor - On intention? (Nose to finger testing) 5. Fine motor/bradykinesia – finger tapping on desk ‘as though playing the piano’ 6. Assess tone at wrist and elbow (cog-wheeling, lead pipe rigidity) assess symmetry - passive movements

Answer 39

**Locomotion (Parkinsonism) Examination - Speech** Ask the patient a question about their life in general as you are assessing upper limb tone - eg. Ask the patient how their day has been so far? How they got into hospital? What they would normally be doing on a 'Tuesday'? History of their symptoms? Check speech: 1. Monotonous 2. Quiet 3. Palilalia (repeating end of word)

Answer 40

Locomotion (Parkinsonism) Examination - Handwriting Ask the patient to write "The dog went to the park." followed by their name and address. - Look for micrographia

Answer 41

**Locomotion (Parkinsonism) Examination - Parkinson's Plus** 1. Eye movements - H pattern = loss of vertical (Idiopathic parkinsons) & loss of vertical and horizontal (progressive suprnuclear palsy) 2. Autonomic dysfunction - BP on lying and standing & feel brow for sweatiness 3. MMSE for dementia

Answer 42

**Speech & Higher Centres Examination Protocol ** 1. Introduction 2. Exposure and Positioning 3. General Inspection 4. Language 5. Mouth 6. Parietal Lobe 7. Temporal Lobe 8. Frontal Lobe 9. Cranial Nerves and PNS 10. Other

Block 5 - Neurology Flashcards

(73 cards)