Neuro Exam Info Flashcards

Question

Lower limb Reflexes: x 3 items

Answer 1

Knee jerk (L3, L4): - w Pt seated legs dependant: strike patellar tendon [watch for contraction of quadriceps] (Can be done supine w Ex supporting flexed knee) Ankle jerk (S1, S2): - w foot in mid- position, knee bent & thigh externally rotated (easier on bed) while maintaining dorsiflexion at ankle: strike Achilles tendon [watch for plantar flexion] (Can be done sitting w foot held in dorsiflexion) Plantar reflex (L5, S1, S2): - w Pt supine or seated: stroke lateral surface of foot from heel to ball of foot w blunt object [watch for flexion of big toe] Babibski’s response: extension of big toe & fanning of other toes. Normal in infants BUT = UMN lesion in adults.

Answer 2

C3- front of neck T4- nipples T7- xiphisternum T10- umbilicus L1- inguinal L2- upper anterior thigh L3- area around front of knee L4- medial aspect of leg L5- lateral aspect of leg S1- heel & sole of foot S2- posterior aspect of thigh

Answer 3

Less is more Start distally & work proximally Sensory modalities: - pain/temp (spinothalamic tract) - position/vibration (posterior column) - light tough (posterior column & spinothalamic tract)

Answer 4

Pain: - demonstrate first (sternum) - arms In anatomical position - compare L & R in same dermatomes - ask if sharp or dull - can be done eyes open or closed Proprioception: - demonstrate w little finger - demo w eyes open - test w eyes closed & get Pt to identify the random Up & Downs - any abnormality distally, work more proximal to wrists or even elbow. [loss of position sense: posterior column Dx or lesion in peripheral nerve or root] Vibration: - 128Hz tuning fork - demonstrate vibrating fork on sternum - perform test w eyes closed - place on DIP joint of thumb while vibrating & ask Pt to indicate when stopped - abnormality distally, work proximally on bot prominences: head of ulna at wrist or olecranon process at elbow. [first sensation lost in peripheral neuropathy, eg; diabetes] Light touch: - cotton wool - demonstrate first - test w eyes closed - compare L & R & each dermatome - do not Stroke Temperature: - not normally tested regularly - can use metal object - start distally & move proximally rapidly asking if temp changes - better tolerated then Pain!!

Answer 5

Pain: - demo on sternum - legs in anatomical position - compare L & R dermatomes - ask if it feels sharp or dull - eyes open or closed - if sensation decreased peripherally: assess for ‘stocking’ sensory loss (rapid pricks from toes up tibia) Proprioception: - passively move Pt’s DIP of big toe - demo eyes open - test eyes closed & get Pt to identify random Up & Downs - if abnormal distally, work proximally: ankle or even knee Vibration: - 128 Hz fork - demo vibrating on sternum - eyes closed, test on DIP of big toe: vibrating & when it stops - compare L & R - abnormality distally, work proximally: malleoli to patella. Light touch: - cotton wool - tested last - eyes closed & say Yes when touch felt - compare L & R dermatomes - do not Stroke Temperature: - not tested regularly - distal to proximal rapidly & ask if temp changes - better tolerated than Pain!!

Answer 6

Rapid alternating movements: - ask Pt to supinate & pronate one hand on other palm as rapidly as possible - Dysdiadochokinesis: slow, clumsy or irregular = cerebellar dysfunction, pyramidal or extrapyramidal tract abnormalities. - DDK performance by Non-dominant hand can also be slow & inaccurate Finger Nose Test: - eyes open, ask Pt to touch finger to nose then Ex’s finger at nearly full extension range - Ex moves finger to 2-3 diff locations - eyes closed: look for past pointing & intention tremor [cerebellar dysfunction] Rebound: - ask Pt to lift arms rapidly from the sides & then stop - hyptonia due to Cerebellar Dx can cause delay in stopping arms

Answer 7

Heel to Shin test: - w Pt supine, heel of one foot on opposite knee & slide down shin to big toe, at moderate pace & as accurately as poss - clumsy movements, or heel moving from side to side, over shoots position = cerebellar dysfunction Toe-Finger test: - ask Pt to lift foot & touch Ex’s finger Foot-tapping test: - ask Pt to tap foot on Ex’s hand as fast & as accurately as poss.

Answer 8

Bone Vs air conduction - 512 Hz tuning fork - vibration on mastoid process 2-3 secs Vs vibration of forks parallel & 1 cm from ear, 2-3 secs Normal: - air louder then bone: Rinne’s Positive Conductive hearing loss: - bone louder than air: Rinne’s Negative Sensorineural hearing loss: - air louder than bone (Rinne’s false pos)

Answer 9

Comparison of L & R hearing - 512 Hz fork - place vibrating fork on cranial midline - ask Pt if sound is louder in one ear than the other? Normal: - sound heard in midline/balanced Conductive hearing loss: - sound heard in Bad ear Sensorineural hearing loss: - sound heard in Good ear

Answer 10

Scars Wasting of muscles Involuntary movements Fasciculations Tremor

Answer 11

Central- brainstem or cerebellum Peripheral- vestibular apparatus or 8th cranial nerve Systemic- psychogenic, cardiovascular, metabolic, trauma or toxicity aetiologies

Answer 12

Check: - general appearance - vital signs - ECG to rule out arrhythmias - BGL to rule out hypo/hyper - assess for gross neurological signs: facial palsy, hemiparesis, limb ataxia or gait issues - cranial nerve assessment: esp. 2, 3, 4, 5, 6 & 7… w particular focus on 8th! (Rinne’s & Weber’s tests) - assess Cerebellum & it’s connections: gait, coordination, reflexes, Romberg test, finger to nose test - perform Ear exam - perform positional nystagmus testing (Dix-Hallpike)

Answer 13

May include: - BGL - Hb - renal & liver function tests - ECG +/- Halter monitoring - audiometry - rotational tests - radiology eg; MRI

Answer 14

Explain & encourage: self-limiting in a few weeks Rest from normal activities or triggers For BPPV - Epley manoeuvre May assist Labyrinthine sedatives: prochlorperazine in acute stage, for a few days Max. (Prolonged use can prevent compensation) Consider: antihistamines or antiemetics to ameliorate vertigo

Answer 15

- accompanying neurological signs - ataxia out of proportion to vertigo - nystagmus out of proportion to vertigo - central nystagmus - central eye movement abnormalities

Answer 16

- sit Pt on exam table & turn head to one side 45 degrees - place Pt supine rapidly so head hangs over edge of bed (ask Pt to keep eyes open) - keep Pt in this position for 30 secs or no nystagmus occurs - return Pt to upright sitting position & observe of another 30 secs to see if nystagmus occurs - Repeat with head turned to opposite side Notes: - will tend to aggravate paroxysmal vertigo & nystagmus if posterior canal dysfunction is present in inner ear - nystagmus will appear after a latency of a few secs & generally last less than 30secs - generally, eyes will beat toward the ground & then when repositioned they will beat towards the opposite direction - this test may induce nausea & vomiting

Answer 17

Classic triad: vertigo, hearing loss & tinnitus Dx: increased endolymph in cochlea & labyrinth, unknown pathogenesis - usually 30-50yo w equal prevalence across genders - usually unilateral, but may become bilateral across time Symptoms: - vertigo - tinnitus - nausea & vomiting - sweating & pallor - progressive hearing loss - nystagmus observed only during an attack Hx: - abrupt onset - variable ear pressure/fullness/decreased hearing & tinnitus - episodes 30mins to hrs - variable time interval between attacks - may be prev Hx of same

Answer 18

Any neck pathology: - cervical instability - # ondontoid peg - recent cervical spine # - Atlantic-axial subluxation - cervical disc prolapse - vertebra-basilar insufficiency - recent neck trauma that restricts torsional movement - cervical myelopathy - recent neck surgery - rheumatoid arthritis affecting neck Carotid bruits! Prior cerebrovascular Dx - carotid sinus syncope - cardiac bypass

Answer 19

- severe neck pain - severe back pain - severe orthopnoea may restrict duration of test

Answer 20

May include: - injury due to associated falls - anxiety symptoms - disability due to unpredictable vertigo - progressive imbalance or deafness - intractable tinnitus

Answer 21

- notify Pt about disease to reduce anxiety (often fear malignancy) - avoid excessive intake: salt, caffeine, tobacco - low salt diet <3gm per day - stress management techniques - ensure Pt has regular check ups w PC Phys - advise Pt around further sources of info/Ed

Answer 22

Ind: rotatory nystagmus Prep: pillow under shoulders to give room for head support Start: - sitting & like Dix-Hallpike: 45 degree turn - go supine, holding 45 d turn for 30-60secs - turn head to other side (45 d angle opposite side) & Hold 30-60secs - turn head a further 90 d (req Pt to roll onto side & keep head at same position) ?Hold - assist to sitting

Answer 23

Ind: lateral nystagmus Prep: lie so head supported by bed Start: - supine: turn head 90 d to one side, Hold 30-60secs - turn a further 90 d, onto side, head facing down, Hold 30-60secs - turn a further 90 d, onto front, head facing over shoulder, Hold 30-60secs - turn final 90 d to original position & Hold 30-60secs - assist to sitting

Answer 24

Ind: vertical nystagmus Prep: edge of bed so head hangs down when supine Start: - supine on bed, shoulders on edge, head hanging as low as poss, Hold 30-60 secs - lift chin to chest (probable support req!), Hold 30-60secs - assist Pt to sitting

Answer 25

Triggers: - sound, odour, oestrogen fluctuations - Foods: red wine, chocolate, ripe cheese, foods containing tyramine or tryptophan - stress Clin focus: - no one Rx superior in all respects - pharmacologic app: directed by severity, associated N&V, Rx setting & Pt specific factors (ie; vascular risk factors/drug preference) - non-pharmacologic: Pt preference - symptomatic Rx: more effective when given earlier & one dose, not repeat small doses - oral agents: many are ineffective because of poor absorption 2nd to migraine-induced gastric stasis

Answer 26

- simple analgesics: some Pt’s respond well to aspirin, NSAIDs, paracetamol - anti-emetics: IV metoclopramide, chlorpromazine, & prochlorperazine - dopamine receptor antagonists & found to be effective in reducing pain - opioids & barbiturates: Last resort Only!! (High risk & assoc w chronic migraine development) - Triptans: selective 5-HT agonists that cause cranial vasoconstriction, peripheral inhibition & inhibition of transmission thru 2nd-order neurons of trigeminocervical complex: first line abortive therapy though effective w pain in migraines 15-80% of Pts. Onset: 10-120mins, some side effects tho: heat, tingling, chest discomfort & injection site reactions. (Check contraindications!) - Crystalloid IV solution: rehydrate vomiting Pts. Standard doses: Aspirin - 300-900mg Ibuprofen - 200-400mg Naproxen - 750mg initial; 250-500mg after 1 hr if needed Diclofenac - 75-150mg Ketorolac - 10mg IM initial; then 10-30mg every 4-6hrs Paracetamol - 1000mg Antiemetics: Metoclopramide - 10mg IV/IM Prochlorperazine - 12.5mg IM Ondansetron - 4-8mg IV/IM/wafer Triptans: Sumatriptan (most commonly used) 6mg SC. Alternate: eletriptan, naratriptan, rizatriptan. Mild-Mod: - no N&V - simple analgesics - w N&V - add antiemetic & consider parenteral/rectal routes Mod-Severe: - no N&V - oral options firstline, inc Triptans - w N&V - parental routes for Triptans & antiemetics Combo Rx: - synergistic effect of Sumatriptan & Naproxen; significant improvement by 2hrs Non-pharmacological: - rest in quiet, darkened cool room - cool packs to forehead/neck - avoid: tea, coffee, orange juice - avoid: moving around too much - don’t read/watch TV

Neuro Exam Info Flashcards

(50 cards)