What are the three basic functions of the nervous system?
Sensory, Integrative, Motor
Which neurons are specific to the sensory function of the nervous system?
Afferent neurons
Which neurons detect internal and external stimuli? On behalf of which function of the nervous system?
Afferent neurons; sensory function
Which neurons are specific to the integrative function of the nervous system?
Interneurons
Which neurons process, analyze, and store information? On behalf of which function of the nervous system?
Interneurons; integrative function
Which function of the nervous system involves interneurons?
Integrative
Which function of the nervous system involves afferent neurons?
Sensory
Which function of the nervous system involves efferent neurons?
Motor
Which neurons respond to integrated decisions? On behalf of which function of the nervous system?
Efferent neurons; motor function
Which neurons are specific to the motor function of the nervous system?
Efferent neurons
Which neurons carry information to cells of the body?
Efferent neurons
What are the two parts of the nervous system?
1) Central nervous system
2) Peripheral nervous system
Which nervous system includes the brain and spinal cord?
CNS
The CNS includes the:
brain and spinal cord
Which nervous system integrates and correlates incoming sensory information?
CNS
Which nervous system is responsible for thoughts, emotions, and memories?
CNS
Which nervous system controls muscle contraction + glandular secretions?
CNS
From where to where does the spinal cord run?
From the medulla to the 1st or 2nd lumbar vertebrae
What type of nerve pathways does the spinal cord contain? How do those pathways enter/exit the spinal cord?
Motor and sensory nerve pathways
Enter/exit via nerve roots + spinal and peripheral nerves
What mediates reflex activity of the deep tendon reflexes?
Spinal cord
Which type of nerve controls deep tendon reflexes?
Spinal nerve
What are the five segments of the spinal cord?
C1-7; T1-12; L1-5; S1-5; coccygeal
What level is the cauda equina?
L1-L2
What does cauda equina mean?
horse tail
What is cauda equina syndrome?
Back pain and saddle anesthesia at S3-S5
In cauda equina syndrome, which parts of the body feel pain?
Perineum, external genitalia, anus
Where are most lumbar punctures performed?
At the L2-L4 interspace
Which nervous system includes spinal nerves, cranial nerves, ganglia, and sensory receptors?
PNS
Parts of the peripheral nervous system?
Somatic nervous system
Autonomic nervous system
Enteric nervous system
Which aspect of the PNS serves as the “pacemaker of the gut”?
Enteric nervous system
How many pairs of cranial nerves are there? How many come from the brainstem?
12 pairs; 10 from brainstem
Which cranial nerve is responsible for sense of smell?
CN I; olfactory nerve
Which cranial nerve is responsible for visual acuity and visual fields?
CN II; optic nerve
Which cranial nerve is responsible for pupillary movements, extraocular movements?
CN III; oculomotor nerve
In addition to CN VI, which cranial nerve is responsible for extraocular movements only?
CN IV; trochlear nerve
Which cranial nerve is responsible for corneal reflexes, facial sensation, jaw movements, voice and speech?
CN V; trigeminal nerve
In addition to CN IV, which cranial nerve is responsible for extraocular movements only?
CN VI; abducens nerve
Which cranial nerve is responsible for facial movements, voice and speech?
CN VII; facial nerve
Which cranial nerve is responsible for hearing and balance?
CN VIII; vestibular nerve
Which cranial nerve is responsible for swallowing and rise of palate, gag reflex?
CN IX; glossopharyngeal nerve
Which cranial nerve is responsible for voice and speech, swallowing and rise of the palate, gag reflex?
CN X; vagus nerve
Which cranial nerve is responsible for shoulder and neck movements?
CN XI; accessory nerve
Which cranial nerve is responsible for tongue symmetry and position, voice and speech?
CN XII; hypoglossal nerve
How many pairs of spinal nerves are there?
31 pairs
How many cervical nerves are there?
8
How many thoracic nerves are there?
12
How many lumbar nerves are there?
5
How many sacral nerves are there?
5
How many coccygeal nerves are there?
1
Each spinal nerve has two roots:
Anterior (Ventral) + Posterior (Dorsal)
Dorsal root =
sensory
Ventral root =
motor
How do sensory nerve fibers send an impulse to the spinal cord?
Via peripheral nerve
From the spinal cord, where does a signal travel?
To anterior horn where sensory fiber synapses with cell innervating same muscle
When does the muscle contract?
When the impulse crosses the neuromuscular junction
What completes the reflex arc?
Contraction of muscle
Which reflex affects T7-9?
Upper abdominal
Which reflex affects T10-11?
Lower abdominal
Which reflex affects T12, L1-2 in males?
Cremaster
Which reflex affects L4-5, S1-2?
Plantar
Which reflexes affect C5-6?
Biceps and brachioradialis
How to test biceps reflex?
Put your thumb on patient’s biceps tendon and hit it with a hammer; the arm should fly up.
How to test brachioradialis reflex?
Have patient pronate arm on their lap and hit inches above wrist; should see subtle rotation
Which reflex affects C6-8?
Triceps
When you hit the triceps tendon, the patient’s arm will move
laterally
Which reflex affects L2-4?
Patellar
In which direction should toe move during a patellar reflex test?
Downward
If a toe moves upward during patellar reflex test:
positive Babinski sign
Which reflex affects S1-2?
Achilles
A band of skin innervated by the sensory root of a single spinal nerve
dermatome
Carpal tunnel syndrome is due to
median nerve compression
Example of virus that hibernates in nerve ganglia
Varicella zoster, chicken pox and herpes zoster
Herpes zoster manifests itself on what region of body most commonly?
Thoracic
Questions you should ask if your patient has h/o seizures?
Type of? Medications? Occur on one side of body? Last seizure?
What are the five levels of consciousness?
Alert Lethargy Obtundation Stupor Coma
Level of consciousness where patient will recognize you when you speak in a normal voice
Alert
Level of consciousness where patient will recognize you when you speak in a loud voice
Lethargy
Level of consciousness where patient is aroused with gentle shaking
Obtundation
Level of consciousness where patient is aroused with painful stimuli
Stupor
Level of consciousness where patient is not arousable with painful stimuli
Coma
Maximum score on Glasgow coma scale
15
Minimum score on Glasgow coma scale
3
What are two ways you may assess your patient’s attention level?
Ask them to repeat a series of digits.
Ask them to spell WORLD backwards
Best way to test patient comprehension level?
Ask them to follow a three-step command
Drawing a clock assesses what part of mental status?
Memory–constructional ability
Proverbs assess what part of mental status?
Higher cognitive abilities
What are three cortical functions that may be compromised by subpar mental status?
Ideomotor apraxia
Ideational apraxia
Right to left orientation
How to test CN I (olfactory)?
Have patient identify familiar odors, one nostril at a time, eyes closed
How to test CN II (optic)?
Test visual acuity and visual fields.
How to test CN III, IV, VI?
Observe pupil size, shape, and reaction to light.
Check for drooping eyelid.
Test extraocular movements.
Which nerve is tested by palpating strength of muscle contractions over temporal and masseter areas while patient clenches teeth?
CN V; trigeminal nerve
Which nerve is tested by inspecting for symmetry in facial expressions?
CN VII; facial nerve
How to test CN VIII (acoustic)?
Test hearing
Which nerves are tested by assessing voice quality, observing swallow, testing gag reflex, and movement of the soft palate and uvula with phonation?
CN IX, X; glossopharyngeal and vagus nerves
Which nerve is tested by inspecting for atrophy or fasciculation in trapezius muscles, testing strength and contraction of trapezius and sternomastoid muscles?
CN XI; spinal accessory nerve
Which nerve is tested by inspecting for tongue midline with protrusion and directed movements of tongue, observing quality of speech, and testing strength of tongue?
CN XII; hypoglossal nerve
How is muscle strength tested? What defines normal
Graded on scale of 0 to 5
Score of 5 = normal
0 on muscle scale =
no muscular contraction
3 on muscle scale =
active movement against gravity
5 on muscle scale =
active movement against resistance
If you observe your patient making rapid alternating movements, observe their gait, and observe them standing in specific positions, you are testing their:
coordination
Under what conditions do you test a patient’s sensory system?
Patient’s eyes are closed; compare symmetrical areas on patient
What are five aspects of the sensory system we test?
Light tough Superficial pain Temperature Vibration Position
How do you test vibration in sensory exam?
Use a tuning fork over interphalangeal joints of the hands and feet
How do you test position?
Use great toe and ring finger; have patients distinguish between whether those two digits are pointing up or down.
What are the five discriminative sensations?
Stereognosis Graphesthesia Two-point localization Point localization Extinction
How to test sterognosis?
Identification of familiar objects in patient’s hand
How to test graphesthesia?
Write on patient’s hand with something blunt and have them identify what number or letter you wrote
How to test two-point localization?
Find the minimal distance on a patient’s finger or thumb that they are able to discriminate between two points
How to test point localization?
Patient identifies where you have touched them briefly
How to test extinction?
Simultaneously touch two spots on body and have patient point to location that was touched
Which systems are in charge of coordination?
Cerebellar system, motor system, vestibular system + sensory system
What are three areas of testing for coordination?
Rapid alternating movements
Point-to-point testing
Equilibrium
How to test equilibrium?
Observe normal gait, heel-to-toe, walk on toes and on heels
What kind of scale are reflexes graded on?
0-4+ scale
Reflex with 4+ grade:
Very brisk, hyperactive with clonus
Reflex with 3+ grade:
Brisker than average, possibly indicative of disease
Reflex with 2+ grade:
Average, normal
Reflex with 1+ grade:
Somewhat diminished, low normal
Reflex with 0 grade:
No response
Normal reflex grade?
2+
A ROM exam can also test?
Strength of muscles
Two pairs of possible movements in fingers?
Flexion/extension
Abduction/adduction
Three types of movements in thumbs?
Flexion/extension
Abduction/adduction
Opposition
Two types of movements in wrist?
Flexion/extension
Radial/ulnar deviation
Type of movement in wrist?
Pronation/supination
Type of movement in elbow?
Flexion/extension
Type of movements in shoulder?
Flexion/extension
Internal/external rotation
Abduction/adduction
Type of movements in neck?
Flexion/extension
Right/left bending
Right/left rotation
Type of movement in toes?
Flexion/extension
Type of movements in ankle?
Inversion/eversion
Dorsiflexion/plantar flexion
Type of movement in knee?
Flexion/extension
Type of movements in hip?
Flexion/extension
Abduction/adduction
Internal/external rotation
Type of movements in spine?
Flexion/extension
Right/left bending
Right/left rotation
The ROM the patient is able to accomplish on their own
Active ROM
The ROM when the examiner manipulates the joint
Passive ROM
Grading of muscle strength is on a scale of:
0-5
The muscle can move the joint it crosses through a FROM, against gravity, and against resistance. Score?
5
The muscle can move the joint it crosses through a FROM against moderate resistance. Score?
4
The muscle can move the joint it crosses through a FROM against gravity but without any resistance. Score?
3
The muscle can move the joint it crosses through a FROM only if the part is properly positioned so that the force of gravity is eliminated. Score?
2
Muscle contraction is seen or identified with palpitation but it is insufficient to produce joint motion even with elimination of gravity. Score?
1
No muscle contraction is seen or identified with palpation; paralysis. Score?
0
In what type of stroke does a weakened/diseased blood vessel rupture, causing blood to leak into brain tissue?
Hemorrhagic stroke
In what type of stroke do blood clots stop the flow of blood to an area of the brain?
Ischemic stroke
Another name for stroke?
Cerebral vascular accident (CVA)
Common symptoms of CVA?
Numb or weak feelings in face, hands, arms or legs
Sudden vision difficulties, inability to view or read properly
Confusion, slurred speech, inability to view or read properly
Severe headache appearing suddenly
Dizziness, difficulty walking
FAST for CVA?
Face
Arms
Speech
Time
Hospitals try to get CVA victim from the door of the hospital into surgery in what time frame?
60 minutes
If patient has hemorrhagic stroke, what specific medication may be contraindicated?
Activase–contraindicated during active bleed
Which specific seizures have an unknown classification?
Epileptic spasms
If seizure activity starts in one area of the brain, it is classified as:
focal seizure
If seizure activity involves both hemispheres of the brain, it is classified as:
generalized seizure
Six types of generalized seizures:
Myoclonic Tonic clonic Clonic Tonic Atonic Absence
Types of myoclonic seizures?
Myoclonic atonic
Myoclonic tonic
Types of absense seizures?
Atypical absense
Myclonic absense
Eyelid myoclonia
What naturally occurring hormone is a seizure treatment?
Adrenocorticotropic Hormone (ACTH)
Which diets are effective for drug-resistant epilepsy?
Ketogenic
Modified Atkins
Alzheimers is defined by the presence of what around the nerve cells in the brain?
Amyloid plaques
Along with amyloid plaques, what other degenerations of the brain are present in Alzheimers patients?
Protein strands twist to damage brain cells
Brain cells die + areas of brain shrink
At what age or older are you most at risk for Alzheimers?
65+
Which disease manifests as severe cortical shrinkage, severe enlarged ventricles, and severe shrinkage of hippocampus?
Alzheimers
Amyloid plaques cause what aspect of the brain to disintegrate?
Microtubules
Which aspect of speech is compromised in MS patients?
Dysarthria–difficulty articulating words
Which aspect of the throat is compromised in MS patients?
Dysphagia–difficultly swallowing
Why might local anesthetics exacerbate symptoms in MS patients?
Due to increased sensitivity of demyelinated axons to local anesthetic toxicity
Which neuromuscular blocking drugs may be used in MS patients?
Non-depolarizing = non-issue Depolarizing = w/ caution
Which aspect of ERAS is especially important for MS patients?
Temperature maintenance
Why must depolarizing NMBDs be used with caution in MS patients?
They may exacerbate hyperkalemia in these patients d/t atrophy in muscular tissue
Which motor system is effected in Parkinson’s patients?
extrapyramidal motor system
Which neurons are primarily effected in Parkinson’s patients?
Dopamineneurons in the substantia nigra
Degeneration of dopamineneurons in substantia nigra leads to:
disruption in the ability to generate body movements
Why should you continue dopamine treatment in Parkinson’s patients the day of surgery?
To stop them may cause rigidity, affecting ability to ventilate
Manifested as flexed joints, tremors, mask-like face, and rigidity
Parkinson’s disease
Progressive neurodegenerative disorder that exhibits a dominant pattern of inheritance
Huntington’s disease
Huntington’s disease is most common in people of
Western European descent; 15:100,000
When do symptoms of Huntington’s disease manifest?
In your 40s
Disease characterized by abnormal movement, cognitive impairment, mood disorders, and behavioral changes
Huntington’s disease
Life expectancy of Huntington’s patient?
15-18 years after onset of symptoms (mid-fifties to early sixties)
A disease characterized by involuntary movements; chorea + dystonia
Huntington’s disease
Progressive neuromuscular disorder characterized by degeneration of spinal motor neurons
Amyotrophic lateral sclerosis (ALS)
Amyotrophic lateral sclerosis (ALS) leads to:
Denervation
Muscle wasting
Paralysis
Death
Most common cause of death in patients with amyotrophic lateral sclerosis (ALS)?
Respiratory failure
What causes muscle wasting in ALS patients?
Voluntary muscles no longer receive commands from brain; atrophy
What is major cause of concern with anesthetics for ALS patients?
Respiratory depression
Why is regional anesthesia contraindicated in ALS patients?
May exacerbate disease
Acute inflammatory demyelinating polyneuropathy that is usually preceded by an infection such as campylobacter jejuni enteritis
Guillain-Barré syndrome
Disease characterized by symmetrical muscle weakness that usually begins in legs an ascends from there, along with paresthesias in hands + feet
Guillain-Barré syndrome
Treatment for GBS?
Plasma exchange
Intravenous immune globulin
What types of drugs should be avoided in patients with GBS?
Depolarizing NMBDs
Due to risk of autonomic instability, use ___________ ____________ with GBS patients.
invasive monitoring
An autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatigue
Myasthenia gravis
Which muscles are commonly affected by myasthenia gravis?
Orbicularis oculi
Masseter
Why does myasthenia gravis cause muscle weakness?
Receptors are blocked by antibodies in the body
If patient has smoothing out of forehead, drooping eye, and drooping corner of mouth, you may suspect:
Myasthenia gravis
Rule regarding depolarizing NMBDs in MG patients?
They will likely require higher dosing
Rule regarding non-depolarizing NMBDs in MG patients?
They will likely be hypersensitive; only require 10% of normal dose
What type of drug should be avoided in MG patients?
Cholinesterase inhibitors, like neostigmine
Most common of several childhood muscular disorders
muscular dystrophy
How is muscular dystrophy hereditary?
X-lined recessive trait
Onset of muscular dystrophy?
Less than 6 years old; usually discovered around 3 yo
Inherited disorder; progressive degeneration of muscle
Muscular dystrophy
If child has delays in motor skill milestones, progressive muscle weakness in legs + pelvic muscles, loss of muscle mass, and abnormal bone development, suspect:
Muscular dystrophy
At what age do MD patients require a brace to walk?
10 years old
At what age are MD patients confined to a wheelchair?
12 years old
Life expectancy of muscular dystrophy patient
Most don’t live past their 30s due to enlarged heart
Which gender gets muscular dystrophy?
Males
MD patients’ reaction to nondepolarizing NMBDs?
Heightened sensitivity
MD patients + sux?
Resistance to blockade and delayed onset
Inhalational agents + MD patients?
Reduce neuromuscular transmission
Beware of which local anesthetics w/ MD patients?
Ester-derived
Spinal cord injury at T6 or higher is called:
Autonomic dysreflexia
Autonomic dysreflexia is triggered by:
sustained stimuli at T6 or below
Patient with autonomic dysreflexia: at level above site of injury:
Vasodilation; sweating, increased heart rate, headaches
Patient with autonomic dysreflexia: at level below site of injury:
Vasoconstriction; pale, cool, no sweating
