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Yr 2 clinical skills > CNS Examination > Flashcards

CNS Examination Flashcards

1
Q

4 main aspects of the examination

A

limbs and gait
cranial nerves
fundoscopy
level of consciousness and higher functions

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2
Q

parts of the limbs examination x7

A

observation

tone

power

coordination

reflexes

sensation

observation of gate

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3
Q

limbs and gait examination : upper limb
1. observation

A

SWIFT

  • Scars and Skeletal
    deformity
  • Muscle wasting/
    atrophy
  • Involuntary
    movements
  • Fasciculation
  • Tremor
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4
Q

limbs and gait examination : upper limb
2. tone x5

A
  1. ask if patient is in any pain
  2. ask patient to relax arms
  3. hold hand and elbow and bend elbow
  4. hold hand and turn hand at wrist
  5. hold hand and bend wrist

repeat on the other side
“no sign of hyper or hypotonia

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5
Q

types of hypertonia: name for increased tone during fast movements

A

spasicity

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6
Q

types of hypertonia: name for increased tone on slow muscle movements

A

rigidity

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7
Q

limbs and gait examination : upper limb
3. power x8

A
  1. shoulders: put elbows in the air “don’t let me push them down”
  2. elbows: flex in front of chest “don’t let me push or pull”
  3. wrists: make a fist and flex “don’t let me stop” flexion of extension
  4. hands: hold fingers out straight, put my hand across “don’t let me stop” moving fingers up
  5. intrinsic hands: spread fingers out “don’t let me push them in”
  6. thumbs- push both sides
  7. grip-squeeze my fingers
  8. pronator drift- arms out, palms up close eyes 15s

test both sides

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8
Q

Medical Research Council (MRC) Scale for power

A

0- No muscle contraction visible
1- Flicker of contraction but no movement
2- Joint movement when effect of gravity eliminated
3- Movement against gravity but not against examiner’s resistance
4- Movement against resistance but weaker than normal
5- Normal power

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9
Q

limbs and gait examination : upper limb
4. coordination x3

A
  1. hold arms out- postural tremor or dystonia
  2. finger nose- “ fast as you can” and move your finger side to side. repeat with other finger

3.Rapid alternating hand movements- hold left hand still and tap fast with right. then alternating flip right hand over. repeat on other side

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10
Q

limbs and gait examination : upper limb
4. reflexes x3

A
  • Biceps: place your thumb or index finger over
    the biceps tendon- in bend of arm strike finger
  • Supinator: place your thumb or index finger
    over a point 3-4 cm above the wrist patents hand should be on side
    and then strike finger.
  • Triceps: strike the tendon directly about 2cm above the elbow whilst supporting the weight of the arm

repeat on both sides

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11
Q

limbs and gait examination : upper limb
5. sensation x3

A

pin prick and cotton will on:
2 down the inner side
3 on the hands
2 on the outer side

vibration sense:
large tuning fork on end of finger
say “as there’s no loss I won’t continue up but if I did I would ensure to place it on bony landmarks such as the radius and olecranon (elbow)”

proprioception:
1. move finger up and down with eye closed. explain and show before

  1. pronator drift: hold hands out palms up. close eyes and wait
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12
Q

limbs and gait examination: lower limbs
1. observation

A

same as before
SWIFT

  • Scars and Skeletal
    deformity
  • Muscle wasting/
    atrophy
  • Involuntary
    movements
  • Fasciculation
  • Tremor
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13
Q

limbs and gait examination: lower limbs
2. tone x3

A

ask if in any pain
relax legs

  1. hip rotation- roll leg about
  2. hip and knee flexion- pick knee up quickly, if heel stays on tone is normal
  3. clonus- sharply flex the ankle up and see if theres any repeated beats

repeat on other side

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14
Q

limbs and gait examination: lower limbs
3. power x4

A
  • Hip: straight leg raise pushing thigh up against
    your hand “keep it there do not let me push it
    down”(flexion) and then pushing down against
    your hand(extension)
  • Knee: bend one knee “pull heel towards your
    bottom” (flexion) and then to straighten the
    knee (extension) “push me away”.
  • Ankle: pull foot back towards them keeping
    their knee straight (dorsiflexion) against your
    hand and then push their foot down against
    your hand (plantarflexion).
  • Extensor Hallux Longus: pull big toe towards
    them (keeping leg straight)
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15
Q

limbs and gait examination: lower limbs
4. coordination

A

heel shin test

take the heel of one leg and put it on the knee of the other leg,
then run the heel down their shin towards the ankle
lifting off at the ankle and back to the knee again, and repeat
the movement.

repeat on both legs

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16
Q

limbs and gait examination: lower limbs
5. reflexes x3

A
  • Knee reflex: place your left forearm under
    one knee and gently lift the leg off the bed
    Strike the patellar tendon, just below the lowest point of
    the patella.
  • Ankle reflex: put foot on other foot
    hold foot and strike achilles tendon

plantar response:
small, reasonably hard but blunt object (such as the blunt end of a Neurotip).
Stroke the lateral side of the sole of the foot firmly
starting near the heel and working up towards toes
and across the ball of the foot towards the base of
the big toe. toe should curl inwards

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17
Q

limbs and gait examination: lower limbs
6. sensation

A
  1. pin prick and cotton swab:
    top of foot
    inner and outer calf
    inner and outer thigh
  2. vibration- large tuning fork
    on big toe
    on sticky out bone of ankle
  3. proprioception
    move toe up and down and ask patient
    large the small movements
  4. proprioception 2- Romberg’s test
    patient to stand feet close together
    one arm in front and behind
    ask to close eyes
18
Q

limbs and gait examination: lower limbs
7. gait x4

A
  1. normal walking- walk along side
    get patient to walk up a hallway, turn on the spot and come back
  2. balance - walk along side
    as before but heel to toe
  3. proximal lower limb power
    rise from a chair without using their arms
  4. distal limb power you can ask the patient
    to walk on their heels and to stand on tip toes.
19
Q

Rinnes results meaning

A

air should be better than bone- positive test

if bone is better than air- conductive loss- negative test

20
Q

Webers result meaning

A
  • sound should be equal
  • louder in problem ear = conductive
    *louder in good ear = sensorineural
21
Q

causes of issues with tones

A

spasticity/hypertonia = upper motor neuron lesion

rigidity = parkinsonism or extra pyrimidal condition

hypotonia = lower motor neuron lesion

22
Q

upper limb:
nerves to remember for myotomes (power) and dermatomes (sensation)
(same as where pinpricking should happen)

A

C5- upper, outer arm
C6- lower outer arm, thumb and index finger
C7- middle finger
C8- ring finger and pinky
T1- inner forearm
(T2- small portion of upper inner arm and armpit)

23
Q

nerves for arm reflexes

A
  • Biceps- C5/6
  • Supinator- C6
  • Triceps- C7
24
Q

lower limb:
nerves to remember for myotomes (power) and dermatomes (sensation)
(same as where pinpricking should happen)

A

L2- upper thigh
L3- middle leg- over knee
L4- backs of calves
L5- shins and top of foot
S1- heel and smallest 2 toes

25
Q

nerves for leg reflexes

A
  • Knee- L3, L4
  • Ankle- S1
26
Q

tip for when testing power

A

always support joint just above joint being testes

27
Q

power on hand: what nerves are tested for each bit x5

A

straight fingers-
extension = radial nerve
flexion = C8

intrinsic (spread fingers)- ulnar

thumb- median

grip- median and ulnar

pronator drift- hemisphere problem

28
Q

cranial nerve overview

A

CN I- ask about smell

CN II-
a) ask about sight or snellen chart
b) pupil response
c)fields
d)fields no movement
e) pen to nose)
f) fundoscopy

CN III, CN IV, CN VI-
a)inspection
b) finger H shape

CN V-
a) cotton wool and prick on forehead, cheek and lower jaw
b) palpate masseter and open jaw against resistance
c) touch cornea with cotton wool

CN VII-
a) inspection- asymmetry
b) face movements

CN VIII-
rinnes/webbers and whisper test

CN IX, CN X-
a) “ahh”
b) cough
c) gag

CN XI-
a) shrug
b) turn face and push

CN XII-
a) inspection
b) tongue into each cheek
c) days of the week

29
Q

what cranial nerves are tested together

A

3, 4, 6 - eye movement
9 and 10- throat

30
Q

Testing cranial nerves: CN I

A

easy- just ask if any loss

31
Q

Testing cranial nerves: CN II x6

A
  1. visual acuity:
    -Ask about any problems with sight
    -can use eye chart or book
  2. pupil responses:
    -get patient to look at a fixed point
    shine light in the eye- direct response

-look at other (non shine) eye- indirect or consensual response

  1. fields
    -sit at same level
    -get patient to cover their right eye
    -cover your left eye

-bring hand from edge of your periphery to theres on 4 corners
-get them to tell you when they can see it

  1. inattention:
    -hold both hands out within fields
    -ask patient to say which hand is moving

-once both sides done wiggle both

-repeat for upper and lower

  1. accommodation:
    -ask to look at tip of pen or finger
    -hold pen of finger away and move towards nose
    -pupils should constrict as the eyes converge.
  2. fundoscopy- see other
32
Q

fundoscopy x2

A

Use your right eye and right hand to examine patient’s right eye and
your left eye and left hand for patient’s left eye

  1. red reflex
    set to 0
    at about 30cm look to see red
    no red = cataracts
  2. positioning
    Right- right of patient
    Left- left of patient
    -“look at distant object”
    - set dial to 0
    - knuckled to cheek
33
Q

findings on fundoscopy x4

A
  • Optic Disc
    -shape
    -colour
    -definition of edges/rim
  • Vessels
    -twisty
    -congested,
    -arteriovenous nipping- arteries constrict veins at crossings
  • Retina Observe
    colour
    haemorrhages
    exudates
    detachment
    tears.
  • Macula Ask patient to look directly at the beam of light just before finishing looking
    at that eye
34
Q

testing cranial nerves: CN III, IV, VI x2

A
  1. inspection
    - ptosis
    - abnormal gaze
  2. keep head still and follow fingers in an H pattern
  • “any double vision”
  • look for nystagmus
35
Q

testing cranial nerves: CN V x3

A
  1. sensation
    - eyes closed
    - cotton wool then neurotip
    - forehead, cheek,jaw “saw when u feel something”
  2. motor
    Palpate the masseter
    ask patient to clench their teeth

open jaw against resistance to test pterygoid muscles.

  1. corneal reflex
    look up to the LEFT and touch the cornea of the RIGHT eye on the lateral side with a wisp of cotton wool.

repeat

blink should be on both sides

36
Q

testing cranial nerves CN VII x2

A
  1. inspection
    facial symmetry
  2. face movements
    -wrinkle their forehead
    -screw up their eyes
    -smile/show their teeth.
    -puff out their cheeks, then press gently
37
Q

testing cranial nerves CN VIII x2

A
  1. nystagmus and balanced normally already tested
  2. hearing
    - rinnes and webers
    -whisper
38
Q

whisper voice test

A
  • Stand 60 cm behind from the ear being tested
    while masking the other ear by gently rubbing the tragus.

in a normal voice say a series of sounds (letters + numbers) and ask the patient to repeat

-repeat using a whispered voice at 60 cm

-If not heard repeat at a distance of 15 cm using a normal voice

-and if this is not heard then escalate to a loud voice at same distance.

39
Q

testing cranial nerves CN IX, X x3

A
  1. inspection
    get patient to open mouth and say “ahh”

palate should move symmetrically and uvula should stay central

  1. cough
    get patient to cough and listen to see if it sounds normal
  2. gag reflex
    touch the side of the throat
    on each side, one at a time

look for reflex contraction of the pharyngeal muscles

40
Q

testing cranial nerves: CN XI x2

A
  1. trapezius
    feel shrugging shoulders- feel for contraction of trapezius
  2. sternocleidomastoid
    -turn their head to one side
    watch for contralateral muscle contract.

The patient should then
push against the side of your fist with their face.

41
Q

testing cranial nerves: CN XII x3

A

Inspection:
-open mouth
- look for fasciculation, wasting or deviation

motor:
-get patient to push tongue in each cheek

-and move side to side

speech:
- say days of the week

Yr 2 clinical skills (14 decks)

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