Flashcards in CN LANGE - Neurologic History & Examination II Deck (66):
Pupillary dilation is controlled by a ...?
3-neuron sympathetic relay, from the hypothalamus, through the brainstem to the T1 level of the spinal cord, to the superior cervical ganglion, and to the eye.
--> Lesions of this pathway result in constricted (
Ocular oscillations - Nystagmus:
1. Can occur at the extremes of voluntary gaze in normal subjects.
2. It may be due to anticonvulsant or sedative drugs.
3. Or reflect disease affecting the extraocular muscles or their innervation, or vestibular or cerebellar pathways.
Nystagmus - The MC form:
Jerk nystagmus - Consists of a slow phase of movement followed by a fast phase in the opposite direction.
To detect nystagmus ...?
The eyes are observed in the primary position and in each of the cardinal positions of gaze.
If nystagmus is observed, it should be described in terms ...?
Of the position of gaze when it occurs, its direction, its amplitude (fine or coarse), precipitating factors such as changes in head position, and associated symptoms, such as vertigo.
The direction of nystagmus is BY CONVENTION ...?
The direction of the FAST phase.
Jerk nystagmus usually increases in amplitude with ...?
... gaze in the direction of the fast phase (Alexander law).
A less common form of nystagmus is ...?
Pendular nystagmus - Which usually begins in infancy and is of equal velocity in both directions.
Compare and contrast the appearances of the 4 eponymous pupils:
Adie (tonic) --> Unilateral large pupil.
Argyll-Robertson --> Bilateral small, irregular pupils.
Horner --> Unilateral small pupil and ptosis.
Marcus-Gunn --> Normal.
Compare and contrast the reactivity (light) of the 4 eponymous pupils:
Adie (tonic) - Sluggish.
Argyll-Robertson - Absent.
Horner - Normal.
Marcus-Gunn - Consensual > Direct.
Compare and contrast the accommodation of the 4 eponymous pupils:
Compare and contrast the site of lesion of the 4 eponymous pupils:
Adie (tonic) - Ciliary ganglion.
Argyll-Robertson - Midbrain.
Horner - Sympathetic innervation of the eye.
Marcus-Gunn - Optic nerve.
Facial weakness may be associated with dysarthria ...?
That is most pronounced for m sounds.
IX lesion - With unilateral weakness, the palate fails to elevate on the ...?
Patients with palatal weakness may also exhibit dysarthria, which affects especially ...?
Tongue weakness also produces dysarthria ...?
With prominent slurring of labial (l) sounds.
Tone is the resistance of a muscle to passive movement at a joint. Abnormally decreased tone (hypotonia or flaccidity) may accompany ...?
Muscle, LMN, or cerebellar disorders.
Increased muscle tone takes the form of ...?
1. Rigidity --> Classically associated with diseases of the basal ganglia.
2. Spasticity --> Classically associated with diseases affecting the corticospinal tract.
Axial tone can be measured by ...?
Passively rotating the patient's head and observing whether the shoulders also move, which indicates increased tone, or by gently but firmly flexing and extending the neck and noting whether resistance is encountered.
In pyramidal weakness (due to lesions affecting the corticospinal tract), there is ...?
Preferential weakness of extensor + abductor in the upper extremity.
Also weakness of flexor muscles in the lower extremity.
Fine finger movements - Pronator drift:
With the arms extended, palms up, and eyes closed, the affected arm falls slowly downward and the hand pronates.
Bilateral symmetrical distal weakness is characteristic of ...?
Polyneuropathy, whereas bilaterally symmetrical PROXIMAL weakness is observed in myopathy.
Somatic sensation is mediated through ...?
Large sensory fibers that travel from the periphery to the thalamus in the posterior columns + Small sensory that ascend to the thalamus in the spinothalamic tracts.
Light touch is conveyed by ...?
Normal joint position sense is ...?
Exquisitely sensitive, and the patient should detect the slightest movement.
Impaired coordination (ataxia), usually results from ...?
Lesions affecting the cerebellum or its connections and can affect the eye movements, speech, limbs, or trunk.
Distal limb ataxia can be detected by asking the patient to perform ...?
Rapid alternating movements (eg alternately tapping the palm and dorsum of the hand on the patient's other hand, or tapping the sole of the foot on the examiner's hand).
Ataxia may be associated with ...?
Intention tremor, which is most prominent at the beginning and end of each movement.
Ataxia of the lower limbs can be demonstrated by the ...?
To detect truncal ataxia, the patient is asked to ...?
Sit on the side of the bed or in a chair without lateral support, and any tendency to list to one side is noted.
Tendon reflexes are graded on a scale according to the force of the contraction or the minimum force needed to elicit the response:
4 - Very brisk, often with rhythmic reflex contraction.
3 - Brisk, but normal.
2 - Normal.
1 - Minimal.
0 - Absent.
The main goal of the reflex testing is to detect ...?
Absence or asymmetry.
Symmetrically absent reflexes suggest ...?
Symmetrically increased reflexes may indicate ...?
Bilateral cerebral or spinal cord disease.
The superficial reflexes are elicited by ...?
Stimulating the skin, rather than tendons, and are altered or absent in disorders, affecting the corticospinal tract.
Several superficial reflexes that are normally present in infancy, and subsequently disappear, may reappear with ...?
Aging or frontal lobe dysfunction.
The palmomental reflex is elicited ...?
By scratching the palm of the hand and results in contraction of ipsilateral chin (mentalis) and perioral (orbicularis oris) muscles.
Elicited by gently tapping the lips and results in their protrusion.
In the rooting reflex, stimulation of the lips causes them to ...?
Deviate toward the stimulus.
The glabellar reflex is elicited by repetitive tapping on the forehead just above the nose. What is the Myerson sign?
Normal subjects blink only in response to the first several taps, whereas persistent blinking is an abnormal response.
Mention the 10 gaits:
1. Hemiplegic gait.
2. Paraplegic gait.
3. Cerebellar ataxic gait.
4. Sensory ataxic gait.
5. Steppage gait.
6. Dystrophic gait.
7. Parkinsonian gait.
8. Choreic gait.
9. Apraxic gait.
10. Antalgic gait.
The affected leg is held extended and internally rotated, the foot is inverted and plantar flexed, and the leg moves in a circular direction at the hip (circumduction).
The gait is slow and stiff, with the legs crossing in front of each other (scissoring).
Cerebellar ataxic gait:
The gait is wide-based and may be associated with staggering or reeling, as if one were drunk.
Sensory ataxic gait:
The gait is wide-based, the feet are slapped down onto the floor, and the patient may watch the feet.
Inability to dorsiflex the foot, often due to a fibular (peroneal) nerve lesion, results in exaggerated elevation of the hip and knee to allow the foot to clear the floor while walking.
Pelvic muscle weakness produces a lordotic, waddling gait.
Posture is flexed, starts are slow, steps are small and shuffling, there is reduced arm swing, and involuntary acceleration (festination) may occur.
The gait is jerky and lurching, but falls are surprisingly rare.
Frontal lobe disease may result in loss of the ability to perform a previously learned act (apraxia), in this case the ability to walk.
--> Patient has difficulty initiating walking and may appear to be glued to the floor.
--> However, there is NO difficulty performing the same leg movements when the patient is lying down and the legs are NOT bearing weight.
One leg is favored over the other in an effort to avoid putting weight on the injured leg and causing pain.
The comatose patient cannot cooperate for a full neurologic examination. A great deal of information can be derived from much more detailed examination, focused on 3 elements:
1. Pupillary reaction to light.
2. Eye movements induced by oculocephalic (head turning), or oculovestibular (cold water caloric) stimulation.
3. The motor response to pain.
"Screening" neurologic examination:
1. Mental status.
2. Cranial nerves.
3. Motor function.
4. Sensory function.
6. Coordination, stance, and gait.
Etiologic categories of neurologic disease (10):
2. Developmental or genetic.
Etiologic category - Degenerative:
Etiologic category - Developmental or genetic:
1. Muscular dystrophies.
2. Arlond-Chiari malformation.
Etiologic category - Immune:
3. Myasthenia Gravis.
Etiologic category - Infectious:
1. Bacterial meningitis.
2. Brain abscess.
3. Viral encephalitis.
4. HIV-associated dementia.
Etiologic category - Metabolic:
1. Hypo/Hyperglycemic coma.
2. Diabetic neuropathies.
3. Hepatic encephalopathy.
Etiologic category - Neoplastic:
2. Metastatic carcinoma.
4. Paraneoplastic syndromes.
Etiologic category - Nutritional:
1. Wernicke encephalopathy (B1).
2. Combined systems disease (B12).
Etiologic category - Toxic:
1. Alcohol-related syndromes.
2. Intoxication with recreational drugs.
3. Side effects of prescription drugs.
Etiologic categories - Traumatic:
1. Sub/epidural hematoma.
2. Entrapment neuropathies.
Etiologic categories - Vascular:
1. Ischemic stroke.
2. Intracerebral hemorrhage.
Normal pupils average ... in diameter in a well-lit room, but ...?
3mm in diameter in a well-lit room, but can vary from 6mm in children to