CENTRAL NERVOUS SYSTEM Flashcards
(76 cards)
1
Q
CNS - GENERAL INSPECTION - SPEECH ABNORMALITIES
A
- Speech abnormalities: may indicate glossopharyngeal or vagus nerve pathology.
2
Q
CNS - GENERAL INSPECTION - FACIAL ASYMMETRY
A
- Facial asymmetry: suggestive of facial nerve palsy.
3
Q
CNS - GENERAL INSPECTION - EYELID ABNORMALITIES
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- Eyelid abnormalities: ptosis may indicate oculomotor nerve pathology.
4
Q
CNS - GENERAL INSPECTION - PUPILLARY ABNORMALITIES
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- Pupillary abnormalities: mydriasis occurs in oculomotor nerve palsy.
5
Q
CNS - GENERAL INSPECTION - STRABISMUS
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- Strabismus: may indicate oculomotor, trochlear or abducens nerve palsy.
6
Q
CNS - GENERAL INSPECTION - LIMBS
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- Limbs: pay attention to the patient’s arms and legs as they enter the room and take a seat noting any abnormalities (e.g. spasticity, weakness, wasting, tremor, fasciculation) which may suggest the presence of a neurological syndrome).
7
Q
CNS - GENERAL INSPECTION - OBJECTS OR EQUIPTMENT
A
- Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status:
- Walking aids: gait issues are associated with a wide range of neurological pathology including Parkinson’s disease, stroke, cerebellar disease and myasthenia gravis.
- Hearing aids: often worn by patients with vestibulocochlear nerve issues (e.g. Meniere’s disease).
- Visual aids: the use of visual prisms or occluders may indicate underlying strabismus.
- Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.
8
Q
CRANIAL NERVES
A
Oh, Oh, Oh, To Touch And Feel a Virgin Girls Vagina And Hymen
1. Olfactory
2. Optic
3. Oculomotor
4. Trochlear
5. Trigeminal
6. Abducens
7. Facial
8. Vestibulocochlear
9. Glossopharyngeal
10. Vagus
11. Accessory
12. Hypoglossal
9
Q
CRANIAL NERVES - MOTOR, SENSORY OR BOTH
A
Some Say Money Matters But My Brother Says Big Brains Matter More
1. Sensory
2. Sensory
3. Motor
4. Motor
5. Both
6. Motor
7. Both
8. Sensory
9. Both
10. Both
11. Motor
12. Motor
10
Q
CN1 - OLFACTROY - FORAMEN/FISSURE
A
Cribriform plate
11
Q
CN1 - OLFACTROY - FUNCTION
A
Sense of smell
12
Q
CN1 - OLFACTORY - SENSORY, MOTOR OR BOTH?
A
SENSORY
13
Q
CN1 - OLFACTROY - TEST
A
- Ask Pt about their smell
- Use different odours (citrus, coffee, mint), unilateral test (cover one nostril)
14
Q
CN1 - OLFACTROY - OUTCOME
A
- Anosmia- genetics, Parkinson’s, fracture of cribriform plate
- Parosmia- bacterial or viral infection
- Hypersomnia- migraine, genetics, epilepsy
15
Q
CN2 - OPTIC - FORAMEN/FISSURE
A
Optic foramen
16
Q
CN2 - OPTIC - FUNCTION
A
Sight
17
Q
CN2 - OPTIC - SENSORY, MOTOR OR BOTH?
A
Sensory
18
Q
CN2 - OPTIC - TEST - VISUAL ACUITY
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- Visual acuity - Snellen wall chart (Unilateral test). Patient covers one eye and reads down the chart until the 6th line if possible.
19
Q
CN2 - OPTIC - TEST - VISUAL FIELD TEST
A
- Visual fields test - Practioner covers opposite eye to patient. Starting with the right eye (patient) using your left arm take it into the periphery and flex your first digit. Pt should be staring at a fixed point (i.e your nose). Following that, with the same eye, use you right arm, perform the same process. Then switch eyes.
20
Q
CN2 - OPTIC - TEST - PUPILLARY REFLEXES
A
- Pupillary reflexes - Patient will cover the mid point in their face creating a divide between the eyes. Shine the light in one eye and observe bi-lateral constriction. Progress then to ‘swinging light test’. Patient will need to focus on a point in front of them, not directly the light.
21
Q
CN2 - OPTIC - OUTCOME - VISUAL ACUITY
A
- Visual acuity - If the patient reads the 6/6 line but gets two letters incorrect, you would record as 6/6 (-2). Could be due to age related muscular degeneration or optic neuritis
22
Q
CN2 - OPTIC - OUTCOME - VISUAL FIELD TEST
A
- Visual fields - Information from the L optic nerve from the L medial field (Nasal field) towards the chiasm but remains on the same side before heading to the visual cortex via the L geniculate body. Information from the L optic nerve from the R lateral field (temporal field) heads towards the chiasm and desiccates and heads towards the L geniculate body. Due to the nature of the anatomy, results can be confusing.
23
Q
CN2 - OPTIC - OUTCOME - PUPILLARY REFLEXES
A
- Pupillary reflex - Direct response suggests the optic nerve is receiving information and the oculomotor nerve is constricting the pupil. Consensual response but no direct response suggests that the optic nerve is receiving the signal but the oculomotor is failing to constrict the pupil. Absent pupillary reflex suggest the optic nerve is not recognising the stimulus. Relative afferent pupillary defect, optic nerves is damaged, both pupils will constrict less when light is shone into the affected eye compared to the healthy eye (large retinal detachment or optic neuritis)
24
Q
CN3 - OCULOMOTOR - FORAMEN/FISSURE
A
Superior orbital fissure
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CN3 - OCULOMOTOR - FUNCTION
The oculomotor nerve supplies all extraocular muscles except the superior oblique (CN4) and the lateral rectus (CN6)
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CN3 - OCULOMOTOR - SENSORY, MOTOR OR BOTH?
Motor
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CN3 - OCULOMOTOR - TEST
- **H-Test**
- **Light pupillary reflex** - Ask the patient to focus on a target approximately half a metre away whilst you shine a pen torch towards both eyes.Inspect the corneal reflex on each eye: If the ocular alignment is normal, the light reflex will be positioned centrally and symmetrically in each pupil. Deflection of the corneal light reflex in one eye suggests a misalignment.
28
CN3 - OCULOMOTOR - OUTCOME
- Ptosis (Innervation to the levator palpebrae superioris) - (Horner’s syndrome, Myasthenia gravis, muscle damage)
- Down and out (Divergent squint)
- Pupil dilation
- Eye movements restricted
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CN4 - TROCHLEAR - FORAMEN/FISSUE
Superior orbital fissure
30
CN4 - TROCHLEAR - FUNCTION
Innervates the superior oblique (ability to look down)
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CN4 - TROCHLEAR - SENSORY, MOTOR OR BOTH?
Motor
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CN4 - TROCHLEAR - TEST
- **H-Test**
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CN4 - TROCHLEAR - OUTCOME
- **Vertical diplopia** - when looking inferiorly, due to loss of the superior oblique’s action of pulling the eye downwards - Diplopia common when going downstairs or reading when palsied
34
CN5 - TRIGMENIAL - FORAMEN/FISSUE
Ophthalmic (Superior orbital fissure)
Maxillary (Foramen rotundum)
Mandibular (Foramen ovale)
35
CN5 - TRIGMENIAL - FUNCTION
**Ophthalmic** - sensory to scalp, forehead, nose and upper eyelid
**Maxillary** - sensory to palate, upper jaw, upper teeth, lower eyelid and nasal cavity
**Mandibular** - sensory to lower lip, lower teeth, anterior 2/3 of tounge, lateral cheek, temporal region. Motor to muscles of mastication, digastric, mylohyoid and the middle ear
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CN5 - TRIGMENIAL - SENSORY, MOTOR OR BOTH?
Sensory and motor
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CN5 - TRIGMENIAL - TEST - SHARP AND SOFT
Sharp and soft sensory test. (Pin & cotton wool) V1,V2,V3) - should be performed in all 3 regions. To ensure the patient understands what is normal, place the cotton wool/pin prick on their sternum or hand for reference. Patient closes eyes and states “sharp” or “soft”. Need to be able to visualise the three separations of the trigeminal nerve:
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CN5 - TRIGMENIAL - TEST - MASTICATION TEST
- Mastication test (V3) - Ask the patient to chew. Encourage them to move from left to right or in a circular motion. Palpate the temporalis, masseter and pterygoids.
39
CN5 - TRIGMENIAL - TEST - JAW REFLEX
- Jaw reflex - Place your left index finger on their chin and striking it with a tendon hammer. This should cause slight protrusion of the jaw. Brisk jaw jerk could be sign of bilateral UMN lesion
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CN5 - TRIGMENIAL - TEST - CORNEAL REFLEX
Corneal reflex
41
CN5 - TRIGMENIAL - OUTCOME
- Loss of sensation
- Loss of distinction between sharp and soft
- Weakness or inability to masticate
- Increased reflex (mouth closing)
- Loss of blinking reflex
- Trigeminal neuralgia - sudden, severe facial pain. It’s often described as a sharp shooting pain or like having an electric shock in the jaw, teeth or gums
- Often associated with MS
42
CN6 - ABDUCENS - FORAMEN/FISSURE
Superior orbital fissure
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CN6 - ABDUCENS - FUNCTION
Innervates the lateral rectus (ability to look laterally)
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CN6 - ABDUCENS - SENSORY, MOTOR OR BOTH?
Motor
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CN6 - ABDUCENS - TEST
- **H-Test**
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CN6 - ABDUCENS - OUTCOME
- Medial gaze – If the lateral rectus fails, the medial rectus will pull the eye inwards.
- Inability to look laterally
- Strabismus – where eyes point in different directions. (Eye alignment). Not to be confused with Amblyopia (lazy eye)
47
CN7 - FACIAL - FORAMEN/FISSURE
Internal auditory meatus / Stylomastoid foramen
48
CN7 - FACIAL - FUNCTION
Sensory taste from the anterior 2/3 of the tongue. Sensation (Part) of external ear and palate. Motor to muscles of facial expression. Innervation of Stapedius. Parasympathetic innervation of salivary glands (sub-mandibular and sub-lingual), lacrimal gland.
49
CN7 - FACIAL - SENSORY, MOTOR OR BOTH?
Sensory and motor
50
CN7 - FACIAL - TEST
- Ask the patient about their taste, hearing and saliva, tears.
- **Facial expression test**- Ask the patient to perform a series of facial expressions (smile, pursed lips) eyebrow raise). Utilise resistance. Resist patient opening eyes. Blowing out cheeks.
51
CN7 - FACIAL - OUTCOME
- Hypoguesia (reduced taste ability) ageusia (loss of taste)
- Loss of hearing noted (tested in conjunction with CN8) (Ramsey Hunt syndrome - Herpes Zoster effects the facial nerve)
- Facial expression test -Facial palsy (Bell’s palsy or stroke)
52
CN8 - VESTIBULARCOCHLEAR - FORAMEN/FISSURE
Internal auditory meatus
53
CN8 - VESTIBULARCOCHLEAR - FUNCTION
sense of hearing and balance
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CN8 - VESTIBULARCOCHLEAR - SENSORY, MOTOR OR BOTH?
Sensory
55
CN8 - VESTIBULARCOCHLEAR - TEST
- Ask the patient about their hearing
- Numbers repetition test
56
CN8 - VESTIBULOCOCHLEAR - TEST - WEBER'S
- **Weber’s** – 512hz tuning fork on the forehead. Can you hear the noise? Should be the same in both ears. If they hear the noise louder in one ear that means: Conductive deafness in ear perceiving the louder sound OR Sensory neural deafness in the other ear.
- Rinne’s and Weber’s are always tested alongside one another
57
CN8 - VESTIBULOCOCHLEAR - TEST - RINNE'S
- **Rinne’s test** – 512 hz tuning fork onto the mastoid process (bone conduction). By the ear (air conduction). Ask the patient if they can hear it. When diminished, bring away from the mastoid process and place outside of the external auditory meatus and ask the patient if they can hear it, air conduction is stronger than bone conduction (normal) confusingly referred to as a “Rinne’s positive” result (air conduction)
- Rinne’s and Weber’s are always tested alongside one another
58
CN8 - VESTIBULARCOCHLEAR - OUTCOME
- **Numbers test** – Air conduction loss
- **Weber’s** - If they hear the noise louder in one ear that means conductive deafness in ear perceiving the louder sound OR sensory neural deafness in the other ear.
- **Rinne’s** – Bone conduction or air conduction loss.
59
CN9 & CN10 - GLOSSOPHARANGEAL & VAGUS - FORAMEN/FISSURE
Jugular foramen
60
CN9 - GLOSSOPHARANGEAL - FUNCTION
provides motor, parasympathetic and sensory information to your mouth and throat. Among its many functions, the nerve helps raise part of your throat, enabling swallowing.
61
CN10 - VAGUS - FUNCTION
vagus nerve is responsible for the regulation of internal organ functions, such as digestion, heart rate, and respiratory rate, as well as vasomotor activity, and certain reflex actions, such as coughing, sneezing, swallowing, and vomiting-
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CN9 & CN10 - GLOSSOPHARANGEAL & VAGUS - SENSORY, MOTOR OR BOTH?
Motor and sensory
63
CN9 & CN10 - GLOSSOPHARANGEAL & VAGUS - TEST - COUGH
- **Ask patient to cough** – can they cough properly from the back of the throat? Is there a Bovin cough.
- Recognise if their voice sounds hoarse.
- Swallowing test - Ask patient to drink a sip of water and observe the ability of the pharynx. Afterwards, has their voice been affected by the water? If so, the glottis may not be functioning.
64
CN9 & CN10 - GLOSSOPHARANGEAL & VAGUS - TEST - UVULA DEVIATION
- **Test for uvula deviation** (“Ah”) Ask the patient to say “ahh“: Inspect the palate and uvula which should elevate symmetrically, with the uvula remaining in the midline. A vagus nerve lesion will cause asymmetrical elevation of the palate and uvula deviation away from the lesion.
65
CN9 & CN10 - GLOSSOPHARANGEAL & VAGUS - GAG REFLEX
- **Gag reflex** - Very uncomfortable and unpleasant. This should not be performed unless there is an overriding reason to do so.
66
CN9 & CN10 - GLOSSOPHARANGEAL & VAGUS - OUTCOME
- Uvula deviation away from the palsied side.
- Weakness in the patient’s voice
- Loss of gag reflex
- Dysphagia
67
CN11 - ACCESSORY - FORAMEN/FISSURE
Foramen magnum / Jugular foramen
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CN11 - ACCESSORY - FUNCTION
Motor to pharynx, trapezius and SCM
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CN11 - ACCESSORY - SENSORY, MOTOR OR BOTH?
Motor
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CN11 - ACCESSORY - TEST
- **SCM test** (Patient rotates their head against practitioner resistance).
- **Trapezius test** (Patient shrugs shoulders against practitioner resistance)
71
CN11 - ACCESSORY - OUTCOME
- Weakness
- Muscle wasting
72
CN12 - HYPOGLOSSAL - FORAMEN/FISSURE
Hypoglossal canal
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CN12 - HYPOGLOSSAL - FUNCTION
Motor to the tounge and throat muscles
74
CN12 - HYPOGLOSSAL - SENSORY, MOTOR OR BOTH?
Motor
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CN12 - HYPOGLOSSAL - TEST
- Resisted tounge movement
- Tounge protrusion
76
CN12 - HYPOGLOSSAL - OUTCOME
- Tongue deviation - In hypoglossal palsy, the tongue will deviate towards the palsied side.
- Tongue weakness
