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Flashcards in Neuro exam Deck (62)
1

Exam flow

Patient interview

Level of consciousness

Cognitive function

Speech and communication

CN

Vital signs

CNS infection or meningeal irritation

increased intracranial pressure secondary to cerebral edema and brain herniation

ANS function

Sensory function

Perceptual function

Motor function

Medical record for diagnostic procedures/results

2

Levels of consciousness

O x3

Determine response to stimuli
-purposefull, nonpurposeful, no response
-verbal, tactile, simple commands
-painful stimuli: pinch, pinprick

Levels of arousal:
-alertness
-lethargy:
-obtundation:
-stupor
-coma
-unresponsive vigilance (vegetative) state
-minimally conscious state (MCS)

3

Lethargy=

appears drowsy, can respond but falls asleep easily

4

Obtundation=

patient can open eyes, lock at examiner, but responds slowly and is confused; demonstrates decreased alertness and interest in environment

5

Stupor=

patient can be aroused from sleep only with painful stimuli

verbal responses are slow or absent

patient returns to unresponsive state when stimuli are removed

demonstrates minimal awareness of self and environment

6

Coma=

a state of unconsciousness from which patient can't be aroused, eyes remain closed; no response to external stimuli or environment

7

unresponsive vigilance (vegetative) state=

a state characterized by the return of sleep/wake cycles, normalization of vegetative functions (respiration, HR, BP, digestion) and lack of cognitive responsiveness (can be aroused but is unaware).

Persistent vegetative state: a state lasting >1 year for TBI and >3 months for anoxic brain injury

8

minimally conscious state (MCS)=

a state characterized by severely altered consciousness with minimal but definite evidence of self or environmental awareness

9

Glascow coma scale

relates consciousness to 3 elements of response:
1- eye opening
2- motor response
3-verbal response

scoring 3-15
-severe brain injury: 1-8
-moderate brain injury: 9-12
-minor brain injury: 13-15

10

Cognitive function exam:

1- memory
-immediate recall
-recent memory
-remote memory (long term)

2- attention
-length of attention span
-sustained attention: ability to attend to task w/o redirection (determine time on task, frequency of redirection)
-divided attention: ability to shift attention from 1 task to another (assess ability of dual task control; getting stuck on a task
-focused attention: ability to stay on task in presence of detractors
-ability to follow commons: single vs. 2 steps

3-emotional responses/behaviors
-safety/judgement; impulsive, lack of inhibition
-affect, mood: irritability, agitation, depression, withdrawal
-frutration tolerance
-self-centeredness
-insight into disability
-ability to follow rules of social conduct
-ability to tolerate criticism

4-higher level cognitive abilities
-judgement, problem solving
-abstract reasoning
-fund of general knowledge
-calculation
-sequencing

5- mini-mental state exam (MMSE)
-includes screening items for orientation, registration, attention and calculation, recall and language
-max score=30
-21-24=mild cognitive impairment
-16-20=moderate impairment
-

11

Speech and communication exam

1- expressive function
-examine fluency of speech, speech production
-nonfluent/Broca's aphasia
-verbal apraxia
-dysarthria

2- receptive function
-examine comprehension
-fluent/Wernicke's/receptive aphasia

3- global aphasia
-severe aphasia
-examine for marked impairments in comprehension and production of language

4- nonverbal communication
-examine ability to read/write
-use of gestures, symbols and pictures

12

Nonfluent aphasia

"Broca's motor aphasia" "expressive aphasia"

a central language disorder in which speech is typically awkward, restricted, interrupted and produced with effort

result of a lesion involving the 3rd frontal convolution of the L hemisphere (Broca's area))

13

Verbal apraxia

impairment of volitional articulatory control secondary to a cortical, dominant hemisphere lesion

14

Dysarthria

impairment of speech production resulting from damage to the central or peripheral NS

causes weakness, paralysis or incoordination of the motor-speech system (respiration, articulation, phonation and movements of the jaw and tongue)

15

Fluent aphasia

"Wernicke's aphasia"
"receptive aphasia"

a central language disorder in which spontaneous speech is preserved and flows smoothly, while auditory comprehension is impaired

the result of a lesion in the posterior 1st temporal gyrus of the L hemisphere (Wernicke's area)

16

Cheyne stokes respiration

a period of apnea lasting 10-60 seconds followed by gradually increasing depth and frequency of respirations

accompanies depression of frontal lobe and diencephalic dysfunction

17

hyperventilation

increased rate and depth of respirations

accompanies dysfunction of lower midbrain and pons

18

apneustic breathing

abnormal respiration marked by prolonged inspiration

accompanies damage to upper pons

19

CNS infection or meningeal irritation exam

*signs are global, not focal

1- neck mobility
-in supine: neck pain with flexion limitation and guarding due to spasm of posterior neck muscles
-can result from meningeal inflammation, arthritis or neck injury

2-Kernig's sign
-in supine; flex hip and knee to chest, then extend knee
- positive sign= causes pain and increased resistance to extend the knee due to spasm of hamstring; when bilateral, suggests meningeal irritation

3- Brudzinski's sign
-in supine, flex neck to chest
-Positive sign= causes flexion of hips and knees (drawing up)-- suggests meningeal irritation

4- irritability

5- slowed mental function
-persistent headache, increased in head down position
-may progress to delirium, lethargy and coma

6- altered VS
-increased HR and RR, fever, fluctuating BP

7- generalized weakness

20

examine for increased intracranial pressure secondary to cerebral edema and brain herniation

1- altered level of consciousness
-progresses from restless and confused to decreasing level of consciousness, unresponsiveness and coma

2-altered VS
-increased BP
-widening pulse pressure and slowing pulse
-irregular respirations- periods of apnea, cheyne-stokes respirations
-elevated temp

3- headache

4- vomiting- secondary to irritation of vagal nuclei

5- pupillary changes (CN III signs)
-examine for ipsilateral dilation of pupil, slowed reaction to light progressing to fixed, dilated pupils (poor prognostic sign)

6- papulledema at entrance to eye

7- progressive impairment of motor function
-examine for weakness, hemiplegia, positive Babinski, decorticate or decerebrate rigidity

8- seizure activity

21

superficial sensations

pain
temp
touch

22

proprioceptive (deep) sensations

joint position sense
kinesthesia (movement sense)
vibration sense (pallesthesia)

23

combined (cortical) sensations

stereognosis= identify familiar objects placed in hand

tactile localization

2 point discrimination

barognosis: identify similar size/shaped objects

graphesthesia: identify numbers, letters traced on skin

bilateral simultaneous stimulation

24

Examine perceptual function

suspect perceptual dysfunction if patient has difficulty with functional mobility skills/ADLs for reasons that can't be accounted for by specific sensory, motor or comprehension deficits

1- homonymous hemianopsia

2- examine for body scheme or image disorders ("somatognosia")
-visual spatial neglect (unilateral neglect)
-R/L discrimination disorder
-Anosognosia: unawareness/denial of impairment

3- spatial relations syndrome
-figure-ground discrimination: pick out specific object from an array of object
-form constancy: pick out a large block from a group of blocks (same shape, different size)
-spatial relations: duplicate a pattern of 2 or 3 blocks
-position in space: demo different limb positions
-topographical disorientation: navigate a familiar route
-depth and distance imperceptions
-vertical disorientation: accurately identify when something is upright/vertical

4- examine for agnosia

5- examine for apraxia

25

homonymous hemianopsia

loss of half of visual field in each eye, contralateral to the side of the cerebral hemisphere lesion

26

Anosognosia=

severe denial, neglect or lack of awareness of severity of condition;

27

agnosia=

inability to recognize familiar objects with one sensory modality while retaining ability to recognize same object with other sensory modalities

28

apraxia=

inability to perform voluntary, learned movements in the absence of loss of sensation, straight, coordination, attention or comprehension

represents a breakdown in the conceptual system or motor production system or both

ideomotor vs. ideational

29

Ideomotor apraxia=

patient can't perform task on command, but can do the task when left on own

30

ideational apraxia=

patient can't perform the task at all, either on command or on own

31

examine motor function

muscle bulk/firmness
-determine whether atrophy is due to denervation, disuse or primary atrophy
-presence of persistent fasciculations suggests neurogenic injury

muscle tone

reflexes

muscle performance: strength, power, endurance

fatigue

voluntary movement control

coordination balance

gait and locomotion

32

Flaccidity and hypotonia

seen in segmental/LMN lesions: nerve roots and peripheral nerve injury

seen initially after suprasegmental/UMN lesions (brief period of spinal shock in SCI, cerebral shock in stroke)

decreased or no resistance to PROM

33

spasticity (spastic hypertonia)

seen in suprasegmental/UMN lesions

increased resistance to PROM; determine whether increasing the speed increases the resistance
*spasticity is velocity-dependent*

Additional signs:
-Clasp knife response: marked resistance to PROM suddenly gives way
-Clonus: maintained stretch stimulus produces a cyclical, spasmodic contraction; common in PF
-Hyperactive cutaneous reflexes, +Babinski: DF of great toe in response to stroking up the lateral side of the sole; indicative of corticospinal tract disruption
-Hyperreflexia: increased DTRs
-some degree of muscle weakness is usually present

Measured by modified Ashworth scale

34

Modified Ashworth scale

grading spasticity

0= no increase in muscle tone

1= slight increase in muscle tone, minimal resistance at end of ROM

1+ =slight increase in muscle tone, minimal resistance through less than 1/2 ROM

2= more marked increase in muscle tone, through most of ROM, affected part easily moved

3= considerable increase in muscle tone, passive movement difficult

4= affected part rigid in flexion or extension

35

Rigidity

increased resistance to PROM that is INDEPENDENT of the velocity of movement

seen in basal ganglia/nigrostriatal disorders: increased resistance to passive movement in agonist and antagonist muscle

Leadpipe: uniform t/o the range

Cogwheel: interrupted by a series of jerks

associated with Parkinson's disease, resting tremor, bradykinesia; strength and reflexes are not affected

36

Decerebrate rigidity/posturing

seen in comatose patients with brainstem lesions between superior colliculus and vestibular nucleus

results in increased tone and sustained posturing of all limbs; trunk/neck in rigid extension

37

Decorticate rigidity/posturing

seen in comatose patients with lesions above superior colliculus

results in increased tone and sustained positioning of UE in flexion and the LEs in extension

38

Opisthotonos

prolonged, severe spasm of muscles, causing the head, back and heels to arch backward; arms and hands are held rigidly flexed

seen in severe meningitis, tetanus, epilepsy and strychnine poisoning

39

examine reflexes

DTR: normally occurring reflexes in response to stretch of muscle

Superficial cutaneous reflexes: normally occurring reflexes in response to noxious stimulus (light scratch) applied to skin

Primitive spinal reflexes

Midbrain/cortical reactions


Reflex scoring for primitive/spinal and tonic/brainstem reflexes:
0= absent
1+ tone change; no visible movement of extremities
2+ visible movement of extremities
3+ exaggerated, full movement of extremities
4+ obligatory and sustained movement, >30 seconds

40

characteristics of UMN syndromes

Location: CNS

Structures: cortex, brainstem, corticospinal tracts, SC

Disorders: stroke, TBI, SCI

Tone: increased, velocity-dependent (spastic)

Reflexes: increased, clonus; exaggerated cutaneous and autonomic reflexes; +Babinski

Involuntary movements: muscle spasms

Strength:
-stroke: weakness of paralysis on one side
-corticospinal lesion: contralateral if above decussation in medulla, ipsilateral if below
-SC lesion: bilateral loss below level of lesion

Muscle bulk: variable, disuse atrophy

Voluntary movements: impaired or absent: dyssynergic patterns, obligatory synergies

41

LMN syndrome characteristics

Location of lesion: PNS

Structures involved:
-SC: anterior horn cells, spinal roots, peripheral nerves
-CN: cranial nerves

Disorders: polio, Guillian-barre, PNI, peripheral neuropathy, radiculopathy

Tone:
-decreased or absent; hypotonia, flaccidity
-not velocity dependent

Reflexes:
-hyporeflexia
-cutaneous reflexes decreased or absent

Involuntary movements: with denervation: fasciculations

Strength: limited distribution; segmental or focal pattern, root innervated pattern

Muscle bulk: neurogenic atrophy; rapid, focal, severe wasting

Voluntary movements: weak or absent if nerve interrupted

42

Clinical issues with strength testing patients with CNS & UMN lesions:

passive restraint: soft tissue changes restrict ability to move (contractures)

Active restraint: spastic muscles restrict ability to move

Abnormal synergistic activity, inappropriate coactivation of muscles

Recruitment problems: abnormal type II fiber recruitment

Abnormal reflex activity: restricts ability to move

Isokinetic dynamometry: patients with UMN syndrome typically demonstrate decreased torque development with increased problems at high speeds, decreased limb excursion, extended time to peak torque development, extended time peak torque held, increased time intervals between reciprocal contractions and changes on "normal" extremities

43

Clinical issues with strength testing patients with PNS and LMN lesions

With myopathies: see proximal weakness of extremities

With neuropathies: see distal weakness of extremities

some conditions produce decremental strength losses (myasthenia gravis)

44

examine for presence of involuntary movements

Extrapyramidal disorders, BG dysfunction:
-Tics
- Chorea
- Athetosis
-Tremor
-Myoclonus

Cerebellar disorders: intention tremor occurring when voluntary movement is attempted

Cortical disorders: epileptic seizures, tonic/clonic convulsive movements

45

Tics=

spasmodic contractions of specific muscles

commonly involving face, head, neck or shoulder muscles

46

Chorea=

relatively quick twitches or "dancing" movements

47

Athetosis=

slow, irregular, twisting, sinuous movements, occurring especially in UEs

48

Tremor=

continuous quivering movements; rhythmic, oscillatory movement observed at rest (resting tremor)

49

Myoclonus=

single, quick jerk

50

Examine coordination

gross motor coordination: body posture, balance and extremity movements involving large muscle groups
-UE tests: finger to nose, alternating movements, supination/pronation, Bilateral symmetrical movements (clapping), bilateral asymmetrical movements (alternate touch knee/shoulder), bilateral unrelated movements (knee pat/elbow extension)
-LE tests: unilateral (heel to shin, foot tapping), etc..
-Postural/trunk tests: whole body movements

Fine motor coordination: extremity movements concerned with use of small muscle groups
-thumb/finger opposition (unilateral, bilateral)
-manual/finger dexterity: grasp and release

Evaluate/document:
-speed/rate control
-control
-steadiness/consistency
-response orientation
-reaction time
-descriptive comments
---scoring: o=unable --> severe, mod, min, 4=normal

51

Dyssynergia=

impaired ability to associate muscles together for complex movement

52

Dysmetria=

impaired ability to judge the distance or ROM

53

Dysdiadochokinesia=

impaired ability to perform rapid alternating movements

54

sensory elements of balance

1- vision
2- somatosensory
3- vestibular

55

postural synergies (strategies) used to preserve balance

1- ankle strategy: DF and PF maintain balance by shifting COM forward//back using a long axis of motion

2-hip strategy: hip and lower trunk muscles shift COM with flexion/ext

3- stepping strategy: rapid steps are taken to realign COM within BOS

56

Functional balance grades

Normal:
-Static: able to maintain steady balance w/o hand held support
-Dynamic: accepts max challenge and can shift weight easily at full range in all directions

Good
-Static: able to maintain balance without hand held support, limited postural sway
-Dynamic: accepts moderate challenge; able to maintain balance while picking object off floor

Fair:
-static: able to maintain balance with hand hold support; may require occasional min assistance
-dynamic: accepts min challenge; able to maintain balance while turning head/trunk

Poor:
-static: requires hand hold support and mod-max assistance to maintain position
-dynamic: unable to accept challenge or move without LOB

Absent

57

ventriculography

x-rays of skill after injection of air into lateral ventricles
-delineates ventricals, helps localize tumors
-useful with increased intracranial pressures

58

myelography

x-rays of spine after injection of air or dye into spinal subarachnoid space

-delineates abnormalities impinging on subarachnoid space
-complications: dye may result in meningeal irritation

59

Cerebral angiography

x rays of skill after injection of dye into carotid and/or vertebral arteries

-largely been replaced my MRA

complications: invasive technique; may cause meningeal irritation, hemorrhage, vasospasm or anaphylactic reaction to dye

60

Computed tomography

neuroimaging technique in which narrow X-ray beams are transmitted through tissues of carrying densities and precisely measured
-allows cross sections (slices) of the brain to be visualized with 3D localization
-can use contrast agents
-useful for showing presence of abnormal changes in tissue density: areas of acute bleeding, cerebral edema, and cerebral infarction

61

spontaneous, ongoing EMG activity

1- Fibrillations: spontaneous, independent contractions of individual muscle fibers; evident with denervation for 1-3 weeks after losing nerve

2- Fasciculations: spontaneous contractions of all or most of the fibers in a motor unit; muscle twitches that can be observed or palpated
-present with LMN disorders and denervation

Complete LMN lesions show only fibrillation potentionals

Partial LMN lesions show fibrillation and fasciculation potentials

62

nerve conduction velocity

conduction velocities are obtained by stimulating peripheral nerves through the skin and recording muscle and sensory nerve action potentials

decreased conduction velocities are seen in peripheral neuropathies characterized by demyelination (Guillian-Barre, chronic demyelinating polyneuropathy, Charcot-Marie-Tooth disease)

slowed conduction velocities seen with focal compression of peripheral nerve