Lectures 3 + 4 - Neurological Exam Flashcards Preview

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Flashcards in Lectures 3 + 4 - Neurological Exam Deck (41):

What is assessed in a neurologic examination?


- Mental State
- Cranial Nerves
- Motor Exam
- Reflexes
- Coordination and Gait
- Sensory Exam


What is assessed in the mental state exam?

- Glasgow coma scale
- level of alertness, attention
- orientation - check if they know where they are
- memory - anterograde, retrograde
- language
- delusions and hallucinations
- mood


What is the glasgow coma scale?

Asks three questions:
- Opening of eyelids
- Motor responses
- Verbal responses

max score = 15
concerning score = 8 and below


What could cause a deficit in levels of alertness, attention and cooperation?

- assess by digit span, or spelling short words backwards

- damage to BRAINSTEM, bilateral lesions of THALAMI or CEREBRAL HEMISPHERES impaires CONSCIOUSNESS

- different focal brain lesions, diffuse abnormalities, dementias and encephalitis, behavioural and mood disorder


What would cause a loss of short term memory?



What causes problems in language?

Lesions in BROCA'S AREA and WERNICKE'S AREA - dominant frontal lobe, left temporal and parietal lobes.

Thalamus also indicated


What causes neglect?

Test for extinction on double simultaneous stimulation

- lesion on right parietal lobe
- lesion on right thalamic or basal ganglia

both causes neglect on left side.


What can delusions and hallcucinations implicate in a neurological examination?

- toxic or metabolic abnormalities
- psychiatric disorder
- focal lesions or seizures in visual, somatosensory auditory cortex.
- lesions in association cortex or limbic system


What can mood problems implicate in neurological examination?

disorder of neurotransmitters

possibly lesion in thyroid


How do we examine CN I?

- smell - peanut butter, coffee, soap

- closed head TBI
- olfactory groove meningioma
- etc


How do we examine CN II

- using an opthalmoscope to check retinas
- Visual acuity using eye chart one eye at a time
- map visual field using fingers
- visual extinction - can they see out of each eye


Where in the eye mostly has cones?


this is where colour vision occurs

fovea has a big representation in brain


What is the optic cup?

This is the blind spot, and is where all the nerves converge.

Raised intercranial pressure will show cupping out of blind spot- it will become CONCAVE


What are the different lesions that can occur to CN II, and how will it present?

In front of the optic chiasm - will affect the ipsilateral eye

Behind the optic chiasm - will affect the contralateral visual FIELD in both eyes


How do we examine CN II and III

- Pupillary responses
Note size at rest, then see if they constrict in light, and accomodate (eyeballs move inwards when looking at something moving closer)
- check for consensual puppilary response - other eye pupil also responding.



What would cause problems in the pupillary response or consensual response?

ipsilateral optic nerve lesions, ipsilateral parasympathetics travelling in the CN III, or problems in pupillary constrictor muscle or iris

contralateral optic nerve for consensual response


How do we examine CN III, IV, VI?

convergent eye movements
smooth eye movements in all directions

abnormalities in individiual eye muscles, or specific cranial nerves

indicates lesions of cerebellum


How do we examine CN V

trigeminal nerve

facial sensation and muscles of mastication

use cotton swab or safety pin


How do we examine CN VII

can be seen in weaknesses or asymmetry between sides of face

can also ask them to smile, frown etc.


lesions in UMN in contralateral motor cortex, descending motor pathways, LMN in ipsilateral facial nerve nucleus, faicla muscles.

eg. stroke - UMN


How do we examine CN VIII

hearing and vestibular sense

- gently rub fingers outside ear

vestibular sense is generally not tested unless patients have vertigo etc.

problems with hearing can result from lesions in the acoustic nerve, or neural elements in the ear, such as cochlea


How do we examine CN IX AND X

palate elevation and gag reflex

does the palate elevate evenly when they say 'aah'

- gag reflex is only tested in patients with suspected brainstem lesions, impaired consciousness or impaired swallowing.


How do we examine VI, VII, IX, X and XII

muscles of articulation

- just listen to the patient speak.
have there been changes?

slurred, hoarse, nasal, low or high, breathy etc.

speech articulation can be affected in lesions of muscles of articulation, neuromuscular junction, or peripheral or central portions of V, VII, IX, X and XII.


How do we examine CN XI

- Sternocleidomastoid and trapezoid muscles

- assessed by asking to shrug shoulders, turn head side to side etc

- weakness can be caused by lesions in muscles, neuromuscular junction, LMN of the CN XI

check back on slide


How do we examine CN XII

- tongue muscles - are there any fasciculations?

- ask to stick tongue out and move it around.

Fasciculations - LMN damage.


Where do upper motor neurons project to?

precentral gyrus
all the way to the pons


Does upper motor neuron damage cause atrophy?


because the connection between the UMN and LMN is fine, which actually innervates the muscle...


What differentiates between acute and chronic UMN lesion presentation?

Acute - flaccid, paralysis, decreased tone.

Chronic (with time) - hyper tonnicity, hyperreflexia


What is drift?

having the patient hold up both arms or legs and then they close their eyes


What do reflexes test for?

LMN lesions, as it goes to the spine and back to the muscle.


Name some reflexes that are often tested

- deep tendon reflex

biceps reflex

brachioradialis reflex

triceps reflex

patellar reflex

achilles reflex

abdominal reflex

- plantar response

they are graded 0 - 5

5 is sustained clonus.


What are frontal release signs?

frontal lobe lesions can sometimes cause the re-emergences of some primitive reflexes that were present in infancy


What is ataxia?

abnormal movement, seen in coordination disorders.

involuntary movements, overshoot...


What is dysdiadochokinesia

an abnormality in rapidly alternating movements.

eg. finger to nose test.

caused by cerebellar lesions, but depends on WHERE the lesion is in the cerebellum.


how do we test Appendicular coordination?

this is testing rapid alternative movements, past pointing, ataxia.

finger to nose test

rapidly toughing thumb to other fingers.


How can you distinguish that an abnormality is due to cerebellar lesion

Normal performance on motor tasks requires multiple sensory and motor pathways, including proprioception, LMN, UMN, basal ganglia and cerebellum.

Thus, you need to test all of the both, including vision and strength, and confirm it is not a LMN problem, or involuntary movement caused by basal ganglia lesios.


What is the romberg test?

Patient is asked to stand with their feet together, and with eyes closed.

See if they start to sway or fall.

This will indicate damage to proprioceptive or vestibular pathways, or to the midline cerebellum...


What can gait tell us?

problems with walking, heel to toe on the floor --> truncal ataxia, from lesions in the midline cerebellum


What are the types of touch examined in the sensory examination?

light touch - test divisions of the trigeminal nerve

and vibratory sensation

temperature sensation


What is Astereognosis?

unable to identify an object in their hands. eg. keys.

stereognosis - ability to do this.


What is agraphaethesia

inability to identify figure ... drawn on their palm


What are somatosensory deficits caused by?

- lesions in the peripheral nerves
- nerve roots
- posterior columns or ventrolateral sensory pathways in SC
- lesions in brainstem, thalamus or sensory cortex.

can distinguish according to what kind of sense - pain and temperature cross in the SC much earlier,

In tact primary sensation but deficits in cortical sensation - graphaestsia, stereognosis = lesion in contralateral sensory cortex.