Flashcards in CN LANGE - Neurologic History & Examination I Deck (95):
Common neurologic complaints include?
6. Blurred vision.
Confusion may be reported by the patient or by family members. Symptoms can include:
1. Memory impairment.
2. Getting lost.
3. Difficulty understanding or producing spoken or written language.
4. Problems with numbers.
5. Faulty judgement.
6. Personality change.
7. Combinations thereof.
Dizziness can mean ...?
1. Vertigo (the illusion of movement of oneself or the environment).
2. Imbalance (unsteadiness due to extrapyramidal, vestibular, cerebellar, or sensory deficits).
3. Presyncope (light-headedness resulting from cerebral hypoperfusion).
Weakness is the term neurologists use to mean ...?
Loss of POWER from disorders affecting motor pathways in the central or peripheral nervous system or skeletal muscle.
Patients use the term weakness to describe ...?
1. Generalized fatigue.
3. Sensory disturbances.
Shaking may represent abnormal movements such as ...?
Correct classification of the shaking depends on ...?
Observing the movements in question or, if they are intermittent and non present when the history is taken, asking the patient to demonstrate them.
Numbness can refer to any of a variety of sensory disturbances ...?
1. Hypesthesia --> Decr. sensitivity.
2. Hyperesthesia --> Incr. sensitivity.
3. Paresthesia ("pins and needles" sensation).
--> Patients occasionally use it to signify weakness.
Blurred vision may represent ...?
2. Ocular oscillations.
3. Reduced visual acuity.
4. Visual field cuts.
Spells imply ...?
Episodic and often recurrent symptoms such as in EPILEPSY or SYNCOPE (fainting).
Neuropathic pain may be accompanied by ...?
An especially unpleasant pain (dysesthetic) accompanied by increased sensitivity to pain (hyperalgesia) or touch (hyperesthesia), or by ALLODYNIA.
What is allodynia?
The perception of a normally innocuous stimulus as painful.
Associated symptoms can often be valuable in the diagnostic process - Give 2 examples?
1. Neck pain accompanying leg weakness suggests a cervical myelopathy.
2. Fever in the setting of headache suggests meningitis.
PMH - Preexisting medical history that can predispose to neurologic disease include ...?
3. Heart disease.
PMH - Operations that may be clinically relevant to the current diagnosis?
1. Open heart surgery may be complicated by stroke or a confusional state.
2. Entrapment neuropathies (disorders of a peripheral nerve due to local pressure) affecting the upper or lower extremity may occur perioperatively.
PMH - Obstetric history relevant to the current diagnosis?
1. Pregnancy can worsen epilepsy, partly due to altered metabolism of anticonvulsants.
2. Pregnancy may increase or decrease the frequency of migraine attacks.
3. Pregnancy is a predisposing condition for idiopathic intracranial HTN (pseudotumor cerebri).
4. Pregnancy is a predisposing factor for entrapment neuropathies (especially CARPAL TUNNEL SYNDROME + Meralgia paresthetica).
5. Traumatic neuropathies affecting the obturator, femoral, or peroneal nerve may result from pressure exerted by the the fatal head or obstetric forceps during delivery.
6. Eclampsia is a life-threatening syndrome in which generalized tonic-clonic seizures complicate the course of pre-eclampsia (HTN + proteinuria) during pregnancy.
History - Age can be a clue to the cause of the neurologic problem?
1. Epilepsy, MS, and Huntington disease usually have their onset by MIDDLE AGE.
2. Alzheimer, Parkinson, brain tumors, and stroke --> OLDER AGE.
Diet as a clue to neurologic disease?
1. B1 def. --> Wernicke-Korsakoff.
2. B3 (niacin) --> Pellagra --> Dementia.
3. B12 --> Dementia.
4. VitE --> Spinal cord degeneration.
5. Hypervitaminosis A --> Pseudotumor cerebri (intracranial HTN).
6. Hypervitaminosis B6 --> Polyneuropathy.
Review of systems - General:
Weight loss or fever may indicate neoplasm or infection.
Review of systems - Immune:
AIDS may lead to dementia, myelopathy, neuropathy, myopathy, or infections (eg toxoplasmosis) or tumors (eg lymphoma) affecting the CNS.
Review of systems - Hematologic:
--> Intracranial hemorrhage.
Review of systems - Endocrine:
1. Diabetes --> Up the risk for stroke + Complicated by polyneuropathy.
2. Hypothyroidism --> May lead to coma, dementia, or ataxia.
Review of systems - Skin:
Characteristic skin lesions are seen in certain disorders that affect the nervous system --> Neurofibromatosis and postherpetic neuralgia.
Review of systems - ENT?
Neck stiffness is a common feature of meningitis and SAH.
Review of systems - Cardiovascular:
Ischemic or valvular heart disease + HTN are major risk factors for stroke.
Review of systems - Respiratory:
Cough, hemoptysis, or night sweats may be manifestations of TB or lung neoplasm --> Can disseminate to the nervous system.
Review of systems - GI:
Hematemesis, jaundice, and diarrhea may suggest hepatic encephalopathy as the cause of the confusional state.
Review of systems - GU:
Urinary retention or incontinence, or impotence, may be manifestations of peripheral neuropathy or myelopathy.
Review of systems - Musculoskeletal:
Muscle pain and tenderness may accompany the myopathy of polymyositis.
Review of systems - Psychiatric?
--> Manifestations of a neurologic disease.
Definition of orthostatic hypotension:
BP that drops by >20mmHg (systolic) or >10mmHg (diastolic) when a patient switches from recumbent to upright.
General physical exam - Pulse:
Especially important if A-fib is present.
General physical exam - Respiratory rate:
May provide a clue to the cause of a metabolic disturbance associated with coma or a confusional state.
1. Tachypnea --> Hepatic encephalopathy, pulm. disorders, sepsis, or salicylate toxicity, neuromuscular disease affecting the diaphragm.
2. Depressed respiration --> Pulm. disorders and sedative drug intoxication.
3. Abnormal respiratory patterns --> In coma (Cheyne-Stokes), in metabolic disorders or hemispheric lesions.
4. Apneustic, cluster , or ataxic breathing --> Brainstem disorder.
General physical exam - Importance of hypothermia:
Can be seen in:
1. Ethanol or sedative drug intoxication.
3. Hepatic encephalopathy.
4. Wernicke encephalopathy.
General physical exam - Skin:
1. Jaundice --> Points to liver disease.
2. Coarse dry skin, dry brittle hair, edema --> Points to hypothyroidism.
3. Petechiae --> Meningococcal meningitis.
4. Petechiae/Ecchymoses --> Coagulopathy as the cause of subdural, intracerebral, or paraspinal hemorrhage.
5. Hot dry skin --> Anticholinergic drug intoxication.
5. Bacterial endocarditis --> Cause of stroke --> Splinter hemorrhages (subungual), Osler nodes (PainFUL swellings of the distal fingers), Janeway lesions (painLESS hemorrhages on the palms and soles).
General PE - Head:
1. Signs of trauma.
2. Battle sign --> Post auricular hematoma from basal skull fracture.
3. Raccoon eyes --> Periorbital hematoma.
5. CSF otorrhea or rhinorrhea.
General PE - Head - Percussion of the skull over a subdural hematoma may ...?
General PE - Head - A bruit heard over the skull is associated with ...?
General PE - Eyes:
1. Icterus --> Liver disease.
2. Kayser-Fleischer --> Corneal rings --> Wilson.
3. Roth spots.
4. Exophthalmos --> Hyperthyroidism, orbital, or retro-orbital masses, and cavernous sinus thrombosis.
General PE - Ears:
Otoscopic exam shows bulging, opacity, and erythema of the tympanic membrane in otitis media, which may spread to produce bacterial meningitis.
General PE - Neck:
1. Meningeal signs --> Meningitis or SAH.
2. Restricted lateral movement --> Cervical spondylosis.
3. Auscultation of the neck may reveal a carotid BRUIT, which may be a risk factor for stroke.
General PE - Chest:
1. Signs of respiratory muscle weakness - Such as intercostal retraction + use of accessory muscles --> May occur in neuromuscular disorders.
2. Heart murmurs --> Inf. endocarditis or valvular heart disease.
General PE - Abdomen:
Abdominal examination may suggest liver disease and is always important in patients with the new onset of back pain --> Panc. carcinoma or AAA may present with pain that radiates to the back.
General PE - Extremities and back:
2. Lasegue --> Stretches the L4-S2 roots and sciatic nerve.
3. Reverse Lasegue --> Stretches the L2-L4 roots and femoral nerve.
4. Localized pain with percussion of the spine may be a sign of vertebral or epidural infection.
5. Auscultation of the spine may reveal a bruit due to spinal vascular malformation.
General PE - Rectal and pelvic:
1. Can provide evidence of GI bleeding --> Precipitant of hepatic encephalopathy.
2. Rectal or pelvic exam may disclose a mass lesion responsible for pain referred to the back.
The neurologic examination (NE) - Main parts:
1. Mental status.
2. Cranial nerves.
3. Motor function.
4. Sensory function.
7. Stance and gait.
The mental status examination addresses 2 key questions:
1. Is level of consciousness (wakefulness or alertness) normal or abnormal?
2. If the level of consciousness permits more detailed examination, is cognitive function normal, and if not, what is the nature of the abnormality?
What is consciousness?
The awareness of the internal or external world, and the level of consciousness is described in terms of the patient's apparent state of wakefulness and response to stimuli.
A patient with normal level of consciousness is ...?
2. ALERT - Responds appropriately to visual or verbal clues.
3. ORIENTED - Knows who and where he or she is and the approximate date or time.
Abnormal (depressed) consciousness represents a continuum ...?
Ranging from mild sleepiness to UNAROUSABLE UNRESPONSIVENESS.
Depressed consciousness short of coma is sometimes referred to as ...?
A confusional state, delirium, or stupor, but should be characterized more precisely in terms of the stimulus-response patterns observed.
--> Progressively more severe impairment of consciousness requires stimuli of increasing intensity to elicit increasingly primitive (non purposeful or reflexive) responses.
The strategy in examining cognitive function is to ...?
Assess a range of specific functions and, if abnormalities are found, to evaluate whether these can be attributed to a specific brain region or require more widespread involvement of the brain.
Bifrontal or diffuse functions - Attention:
Is the ability to focus on a particular sensory stimulus to the exclusion of others.
What is concentration?
How can attention be tested?
By asking the patient to immediately repeat a series of digits (a normal person can repeat 5 to 7 digits correctly).
How can concentration be tested?
By having the patient count backward from 100 by 7.
How can abstract thought processes like insight and judgement be assessed?
1. By asking the patient to list similarities and differences between objects (eg, an apple and an orange).
2. Interpret proverbs (overly concrete interpretation suggest impaired abstraction ability).
3. Describe what he or she would do in a hypothetical situation requiring judgement (eg, finding an addressed envelope on the street).
How can fund of knowledge be assessed?
By asking for information that a normal person of the patient's age and cultural background would possess (eg the name of the President, sports stars, or other celebrities, or major events in the news).
--> This is not intended to test intelligence, but to determine whether the patient has been incorporating new information in the recent past.
What is the affect?
The external behavioral correlate of the patient's (internal) mood and may be manifested by talkativeness or lack thereof, facial expression, and posture.
What is memory?
The ability to register, store, and retrieve information and can be impaired by either diffuse cortical or BILATERAL temporal lobe disease.
How can memory be assessed?
1. Immediate recall.
2. Recent memory.
3. Remote memory.
--> Which corresponds roughly to registration, storage, and retrieval.
Tests of immediate recall are ...?
Similar to tests of ATTENTION and include having the patient immediately repeat a list of numbers or objects.
To test recent memory, the patient can be asked to ...?
Repeat the same list 3 to 5min later.
How is remote memory tested?
By asking the patient about important items he or she can be expected to have learned in past years, such as personal or family data or major historic events.
Confusional states typically impair ...?
Memory disorders (amnesia) are characteristically associated with ...?
Predominant involvement of RECENT memory, with remote memory preserved until late stages.
The key elements of language are ...?
--> ALL should be tested when a language disorder (aphasia) is suspected.
Expressive (also called non fluent, motor, or Broca) aphasia is characterized by ...?
Paucity of spontaneous speech and by the agrammatical and telegraphic nature of the little speech that is produced.
How is language expression tested?
By listening for these abnormalities as the patient speaks spontaneously and answers questions.
Broca - Patients with this syndrome are ALSO unable to ...?
Write normally or to repeat (tested with a content-poor phrase such as "no ifs, ands, or buts"), but their comprehension is intact.
--> If the patient is asked to close its eyes, he or she can do it.
--> Patient is typically unaware of the disorder and frustrated by it.
Wernicke aphasia - Features:
A large volume of language is produced, but it lacks meaning and may include paraphasic errors (use of words that sound SIMILAR to the correct word) + neologisms (made-up words).
Wernicke aphasia - Written language?
Is similarly incoherent + repetition is defective.
Wernicke - The patient cannot follow ...?
Oral or written commands, but can imitate the examiner's action when prompted by a gesture to do so. These patients are usually unaware of and therefore not disturbed by their aphasia.
What may be difficult to distinguish from aphasia?
A speech disorder (dysarthria) --> Always spares oral and written language comprehension and written expression.
Sensory integration disorders result from ...?
Parietal lobe lesions and cause misperception of OR inattention to sensory stimuli on the side of the body opposite to the lesion, even though primary sensory modalities (eg touch) are intact.
--> Patients with PARIETAL lobe lesions may exhibit various signs.
The inability to identify by touch an object placed in the hand, such as a coin, a key, or safety pin.
The inability to identify by touch a number written on the hand.
Misplaced (typically more proximal) localization of a tactile stimulus.
The failure to perceive a visual or tactile stimulus when it is applied BILATERALLY, even though it can be perceived when applied UNILATERALLY.
The failure to attend to space or use the limbs on one side of the body.
Unawareness of neurological deficit.
The inability to draw accurate representations of external space, such as filling in the numbers on a clock face or copying geometric figures.
Motor integration - Praxis and apraxia:
Praxis - The application of motor learning.
Apraxia - The inability to perform previously learned taskes despite intact motor and sensory function.
Tests for apraxia include:
Asking the patient to simulate the use of a key, comb, or fork, without props.
Unilateral apraxias are commonly caused by ...?
Contralateral premotor frontal cortex lesions.
Bilateral apraxias, such as gait apraxia, may be seen with ...?
Bifrontal or diffuse cerebral lesions.
Ophthalmoscopy - Mydriatic eye drops - Contraindications:
1. Should NOT be used until visual acuity and pupillary reflexes are tested.
2. Nor in patients with untreated closed angle glaucoma.
3. Or an intracranial mass lesion that might lead to transtentorial herniation.
In early papilledema, the retinal veins appear ...?
Engorged and spontaneous venous pulsations are ABSENT.
In early papilledema - The disk may be ...?
Hyperemic with linear hemorrhages at its borders.
In fully developed papilledema, the optic disk ...?
Is elevated above the plane of the retina, and blood vessels crossing the disk border are obscured.
Papilledema is almost always ...?
Papilledema does NOT typically impair ...?
Vision except for enlargement of the blind spot, and it not painful.
Optic disc pallor:
Atrophy of the optic nerve.
Optic disc pallor can be seen in ...?
MS or other disorders and is associated with defects in visual acuity, visual fields, or pupillary reactivity.