Neuro Flashcards
(11 cards)
UL neuro exam
WIPER
Aim to distinguish between UMN or LMN lesion
Always compare both sides, looking for any asymmetry
Position patient at 45 degrees with arms exposed
Inspect Tone Power Reflexes Coordination Sensation
Inspection SWIFT • Scars • Wasting • Involuntary movements • Fasciculations • Tremor Also note posture at rest Signs of inflammation Note whether it is local or general
Tone Ask patient to go floppy, and let me move your arms Ask about any pain expected on movement In general looking for: - spasticity - rigidity - pain - restriction Always support joints • Take hold of hand and test supination rapidly then slowly • Flexion and extension at the elbow • Range of movements at the shoulder NB do on both sides
Power Sign post well Always test bilaterally Stabilise joint Test like for like Isolate muscles as much as possible • Shrug shoulders • Chicken • Like a boxer • Hand out in fist • Hand out with fingers flat • Spread your fingers out • Thumb to the ceiling (pull towards palm) • Squeeze my fingers • Hold this paper NB MRC classification 0-5 0 = no contraction 3 = active against gravity 5 = normal
Reflexes Compare both sides sequentially Hold tendon hammer at the end and sw • Supinator (C6) - radial border of distal forearm (2 inches below wrist) • Biceps (C5,6) - make a fist and feel • Triceps (C7) - support limb Can ask to do the Jendrassik manoeuvre Comment on presence, extent and whether reinforcement was needed
Coordination
Hold finger in front of patient, ask to touch their nose and then your finger as fast as you can
- intention tremor
- past pointing
- make sure they have to fully reach out
• Dysdiadochokinesis test - palm then back of hand into other palm
• Pronator drift - eyes closed, arms out with palms up
Sensation Light touch, with cotton wool. Don't rub • Chest first so they know what it feels like • Dermatomes - C7 is middle finger - C5 is deltoid - T2/3 is axilla • Always left vs right Repeat with: • pin prick • temperature • vibration (128Hz tuning fork on bony prominences) Proprioception • Hold distal phalanx on the sides • Ask to close eye and tell you if it is being moved up or down
Neuro history
NB may be difficult due to patient condition
General Q: Outline the progression/onset Continuous, periodic or deteriorating Age Occupation Ethnic origin Right or left hand dominant
Presenting: Headache • different to usual • acute/chronic • speed of onset • recurrent? • unilateral/bilateral • association • ?meningism - leg pain, neck stiffness, photophobia - won't be able to shake their head • worse on waking - increased ICP • faintness
Muscle weakness • onset • groups affected • associated sensory dysfunction • sphincters • loss of balance • associated pain
Visual disturbances • blurring • double vision • photophobia • loss • onset • preceding symptoms • eye pain
?Changes in other special senses
Dizziness • surroundings moving - vertigo • changes to hearing • loss of consciousness • positional
Speech
• expression, articulation, comprehension
• onset
Dysphagia • at what point • solids +/- liquids • constant or intermittent • painful
Fits/faints • frequency • duration • trigger • loss of consciousness • tongue biting • incontinence
Abnormal sensations • numbness • parasthesia • distribution • onset • associated weakness
Tremor • slow or rapid • at rest • worse on movement • beta agonists • thyroid
Cognitive assessment Abbreviated Mental Test Score (AMTS) 1) Tell patient an address to recall at the end 2) ?Age 3) ?Time 4) ?Year 5) Recognise two people 6) DOB 7) Dates of WW2 8) Current monarch or PM 9) Where are you now 10) Count backwards from 20 to 1
Past hx • Meningitis • Encephalopathy • Trauma • Past ops • Risk factors from CVD • Recent travel • Pregnancy
Drug hx • Medication - anticonvulsants - antipsychotics - antidepressants - side effects from others • Psychotropic drugs
Social and family hx
• What do they do, day-to-day
• Family hx of neurological disease
Cramps
Painful muscle spasm
Consider salt depletion:
• Post heavy exercise
• Renal impairment patients
Rarer
• Muscle ischaemia
• Myopathy
• Dystonia
If in forearm, consider MND
Parasthesia
Pins and needles
Causes • Metabolic - decrease in Ca - increase PCO2 - myxoedema (hypothyroid) - neurotoxins • Vascular - arterial emboli - Reynaud's - DVT - high plasma viscosity • Ab-mediated - paraneoplastic - SLE - ITP • Infection - Lyme - Rabies • Drugs - ACEi • Brain - thalamic/parietal lesion • Cord - MS - myelitis/HIV - decrease in B12 - lumbar fracture
• If mononeuropathy - cervical rib - carpal tunnel - sciatica • If peripheral - DM - CKD
Tremor
1) Resting
e.g. Parkinson’s (plus bradykinesia, rigidity)
• Slow ( ~3Hz)
• Pill rolling
2) Postural - worse if arms outstretched • Typically more rapid (~8Hz) • Causes: - exaggerated physiological (anxiety, hyperthryoid, alcohol, drugs) - brain damage (Wilson's, syphilis) - benign essential • Often familial
3) Intention tremor - worse on movement
• Classically with cerebellar disease
- past pointing
- dysdiadochokinesis
UMN vs LMN
UMN - along corticospinal tracts
• Precentral gyrus to the anterior horn (via capsule, brainstem and cord)
• Will affect groups instead of individual muscles
Classically:
- UL extensors
- LL flexors
LMN - anterior horn distally
• including roots, plexuses and peripheral nerves
Paralysis, wasting, reflexes, Babinski, fasciculations, clonus, tone
UMN • Spastic paralysis (UL flexors, LL extensors) - velocity-dependent rigidity • No wasting • Hyper-reflexia • Positive Babinski - upgoing plantars • No fasciculations • Clonus • Increased tone
LMN • Flaccid paralysis • Wasting • Hypo-reflexia • Normal Babinski • Fasciculations • No clonus • Decreased tone
NB mix can occur in:
• MND
• B12 deficiency
• taboparesis
LL neuro examination
WIPER
Expose down to underwear
NB always do both sides and look for asymmetry
Inspect
Gait Ask to walk across room and back: • Use of aids • Symmetry • Size of paces • Arm swing Walk heel to toe, like on a tightrope: • Instability ?Go on tip toes - S1 or gastrocnemius ?Go on heels - L4/5 (foot drop)
Romberg's test: Stand, eyes closed, arms by their side Say you will support them • Imbalance - posterior column disease or sensory ataxia
Others • SWIFT • Abnormal posture • Deformaties - e.g. of foot
Lay them down on the bed
Tone
Relax and go floppy, let me move your legs
Ask for expected pain on movement
• Roll the leg and look for foot delay
• Flexion and extension at each joint
• Again, but when in external and internal rotation
Special:
• Hand behind the knee and raise it quickly
- heel should lift slightly if tone is normal
• Plantar flex the foot then quickly dorsiflex (whilst knee bent)
- feel for any clonus
Reflexes
Right then left Reinforcement if required (Jendrasik) Knee (L3/4) • strike patella tendon Ankle (L5/S1) • bend knee, drop it laterally, dorsiflex foot • strike achilles Plantar reflexes (L5/S1/S2) • Babinski Comment on: • presence • extent • character • need for reinforcement or not
Power Clearly sign post Bilateral sequential Stabilise joint Hip • Leg straight flexion and extension • Abduction - hands on outside of the thighs and ask to push out • Adduction - hands on the inside and ask to push in Knee • Extension and flexion Ankle • Plantar and dorsi flexion Comment on power • 0-5 MRC scale
Coordination
• Heel-shin test
- heel on knee, down the shin, lift to touch my hand, and repeat
Sensation Exactly the same as UL • Light touch • Pin-prick • Temperature • Vibration • Proprioception For dermatomes: L3 is pockets - think that diagonal L4 becomes medial shin and foot L5 lateral shin and top of the foot S1 is lateral side of foot S2 is medial back of leg S3,4,5 near anus
Cranial nerves examination
I - olfactory II - optic III - oculomotor IV - trochlear V - trigeminal VI - abducens VII - facial VIII - vestibulo-cochlear IX - glossopharyngeal X - vagus XI - accessory XII - hypoglossal
I
Noticed any changes in smell
II 1) Acuity • Ideally Snellen chart • 'Can you read this' • Each eye individually 2) Colour • Ideally Ishihara test • What colour is this 3) Accommodation • 'Follow my finger', as you move it towards them (should constrict for near) 4) Pupillary reflex • Direct and consensual (i.e. twice for one eye) • Swinging - looking for paradoxical, relative afferent pupillary defect 5) Field • Touch shoulder, make sure hands are halfway Neglect: - 'point to which finger is moving' - do one at a time then do both - do superior and inferior quadrants For specific eye: NB be very clear with sign-posting - 'I want you to take this hand and cover your eye' - 'I will do the same' - 'Look at my eye' - 'Say when you can see my finger' - 'Now I want you to keep that eye covered, I'm just going to swap my hands over' Comment on any field defects (eye and whether they were nasal or temporal) 6) Fundoscopy • fundus • disc • main vessels
III, IV and VI Eye movement • 'Keeping your head still, follow my finger with your eyes' • Move in H - slow and fast - slow and hold allows to see nystagmus (think vestibular lesion or cerebellar • Place two fingers out - look from one to the other - look for slow, slow onset, overshooting Palsies at rest: • III - Ptosis - Dilated pupil - Down and out • IV - Diplopia - Down and in • VI - Diplopia
V Motor • 'open your mouth' • 'bite down' - feel over masseter (also pterygoid, and temporalis) Sensory • Three divisions on the face - consider corneal reflex (as this is lost first)
VII • Look for drooping face, particularly eyebrows • 'Raise your eyebrows' • 'Show me your teeth' • 'Puff out your cheeks' • 'Any change in taste'
VIII Hearing • Whisper a number whilst rubbing fingers over other ear • Weber's - fork on forehead - which side is louder - Conductive loss - affected side louder - Sensori-neural loss - contralateral louder • Rinne's - 256 or 512Hz tuning fork - hold on mastoid until sound goes - then place in front of ear - air should be better than bone - if vice versa then conductive loss
IX and X • Gag-reflex (e.g. ask to swallow water, or touch soft palate) - IX afferent - X efferent • Ask to say 'ahh' - uvula deviates away from the lesioned side • Cough - recurrent laryngeal on vocal cords
XI • Trapezii - shrug shoulders against resistance • SCM - turn head right and left against resistance
XII
• Tongue
- deviates to the side of the lesion
To complete:
Opthalmoscope
Classic individual cranial nerve injuries
All: • diabetes • stroke • MS • tumours • sarcoidosis • vasculitis • SLE • syphilis
I • trauma (e.g. boxing) • RTI • frontal lobe tumour • meningitis
II • Monocular blindness - lesion of eye - lesion of optic nerve, e.g. MS, giant cell arteritis • Binocular blindness - above - methanol - neurosyphilis • Bitemporal hemianopia - optic chiasm compression, e.g. pituitary tumour, internal carotid aneurysm • Homonymous hemianopia - lesion of tract, radiation, cortex - e.g. stroke, abscess, tumour • Optic neuritis Symptoms - pain on eye movement - loss of central field - relative afferent pupillary defect Cuases - demyelinating disease - sinusitis (rare) - syphilis - collagen vascular disease • Ischaemic papillopathy - disc swelling due to stenosis of posterior ciliary artery • Papilloedema - bilateral disc swelling - due to raised ICP (tumour, abscess, enceph, hydroceph, cavernous sinus thrombosis (rare)) • Optic atrophy - pale discs and reduced acuity Causes - MS - frontal tumours - retinitis pigmentosa - syphilis - glaucoma
III (alone) • Pupillary sparing - diabetes - HTN - giant cell arteritis - syphilis • Pupillary involvement (external compression affecting parsympathetics) - posterior communicating artery aneurysm - increase ICP - tumour
IV (alone)
• very rare
• orbit trauma
V Sensory • trigeminal neuralgia • herpes zoster • nasopharyngeal cancer • acoustic neuroma Motor - rare
VI (alone)
• MS
• Wernicke’s encephalopathy
• Pontine stroke
VII LMN • Bell's • Polio • Otitis media • Skull fracture • Acoutic neuroma • Malignant parotid tumour • herpes zoster UMN (NB spares forehead due to bilateral cortical rep) • Stroke • Tumour
VIII • Noise • Paget's • Meniere's • herpes zoster • acoustic neuroma • brainstem CVA
IX, X, XI
• Trauma
• Brainstem lesions
• Neck tumours
XII (rare) • polio • syringomyelia • tumour • stroke • bulbar palsy • trauma • TB
Grouped cranial nerve injuries
VIII, then V, VI, IX and X
• Cerebellopontine angle tumour
III, IV & VI • Stroke • Tumours • Wernicke's encephalopathy • Aneurysm • MS
III, IV, Va and VI
• cavernous sinus thrombosis
• superior orbital fissure fracture
IX, X & XI
• Jugular foramen lesion
Glasgow Coma Scale
Eye opening 4 - spontaneous 3 - to speech 2 - to pain 1 - no response
Best verbal response 5 - orientated to time, place and person 4 - confused 3 - inappropriate words 2 - incomprehensible sounds 1 - no response
Best motor response 6 - responds to command 5 - moves to localised pain 4 - flexion withdrawal from pain 3 - abnormal flexion 2 - abnormal extension 1 - no response
Total
• Best = 15
• Coma <8
• Totally unresponsive = 3
