Neurologic Flashcards
1
Q
what are ways to assess mental status?
A
- observe physical appearance and behavior
- assess level of consciousness along a continuum
- investigate cognitive abilities
- assess mood, thought, perception and judgement
- observe speech and language
2
Q
define AVPU scale
A
- A = alert
- V = responsive to verbal stimuli
- P = responsive to painful stimuli
- U = unresponive
3
Q
describe Glasgow coma scale
A
- assesses level of consciousness
4
Q
CN I Testing
A
- Olfactory nerve: damage can occur at epithelium in nose, filaments, bulb or tracts to cortex
–> have patient close eyes and occlude one nostril
–> have patient sniff aroma from a vial
–> lack of recognition can be primary mechanical or metabolic
–> Pt c/o inability to smell and or taste
5
Q
CN II Testing
A
- Optic nere - special sensory VISION
- Visual acuity, fundoscopic exam and fields
–> Visual acuity (snellen or rosenbaum eye chart)
–> pupillary response both direct and consensual response
–> Field testing helps you understand defects behind the retina
–> Confrontation testing
6
Q
CN III Test
A
- Motor function (tested via extra-ocular movement)
- parasympathetic function (pupillary response)
PERLA: Pupils equal, reactive to light and accommodation (focus on far then near object (Ciliary muscle))
- assess shape of pupil (may be affected by congenital abnormalities)
- Direct and consensual testing - swinging light test
DEFICITS:
- eye is DOWN AND OUT
- Ptosis
- Dilated pupils
7
Q
CN IV Test
A
- Pure motor (internal torsion)
- defects lead to hypertropia (eye moves up)
8
Q
CN VI test
A
- Pure motor (lateral eye movements)
- Defects lead to esotropia
9
Q
CN V test
A
- Sensory (corneal reflex, facial sensation to light touch/pain and motor)
- corneal reflex = wisp of cotton on cornea
- Facial sensation = Cotton swab and pin to all three branches on both sides
- Ask pt to move jaw up/down and side to side
- Pt c/o pain or jaw weakness with chewing
10
Q
CN VII test
A
- Sensory = tase to anterior 2/3 of tongue and soft palate sensation (Salty and sweet)
- Motor = facial movement (observe face while talking)
- Pt c/o facial asymmetry, drooling, eye dry on one side, noises too loud in one ear
- peripheral nerve injury = bell’s palsey (can’t wrinkle forehead on ipsilateral side)
11
Q
define hyperacusis
A
- early or initial symptom of peripheral VII nerve palsy
- patient is painful sensitivity to sound
- loss of taste also may occur on affected side
12
Q
left peripheral VII facial weakness**
A
- attempt to close eye results in eyeball rolling superiorly exposing sclera but no closure of the lid per se
- patient unable to wrinkle forehead***
- eyelid droops very slightly
- cannot show teeth at all on affected side in attempt to smile and lower lip droops slightly
13
Q
define left centralVII facial weakness
A
- incomplete smile with very subtle flattening of affected nasolabial fold
- relative preservation of brow and forehead movement**
14
Q
Acoustic CN VIII (vestibulocochlear)
A
- Sensory: hearing and equilibrium
- Testing: whisper test, weber test, rinne test, Dix-hallpike maneuver (vertigo test)
- Pt c/o hearing loss and or dizziness
15
Q
CN IX test
A
- motor to stylopharyngeus m
- sensory taste to posterior 1/3 of tongue
- general sensation to tongue and posterior pharynx (GAG REFLEX afferent limb)
- Parasympathetic to parotid gland
16
Q
CN X test
A
- Motor to muscles of pharynx, larynx and palate (gag reflex EFFERENT limb)
- parasympathetic to pulmonary, cardiovascular and gastrointestinal systems
- Sensory to pharynx, larynx, external auditory canal and the thoracic and abdominal viscera
17
Q
CN XI testing
A
- pure motor = sternocleidomastoid and trapezius mm; some laryngeal mm
- testing = resisted turning (eg to test the R SCM, have patient turn head to L); shoulder shrug for trapezius mm
- Defects: pt may c/o asymmetry of shoulders, inability to turn head to opposite side
18
Q
CN XI damage
A
- Damage to the peripheral CN XI gives SAME SIDED TRAPEZIUS and SCM weakness
- Central lesion will weaken the ipsilateral trapezius and contralateral SCM muscle
19
Q
CN XII
A
- Pure motor tongue muscles
- protrude tongue: tongue deviates to side of peripheral lesion, away from side of central lesion (unopposed genioglossus m )
- peripheral lesion may also see atrophy and fasciculations
- Pt has difficulty saying lingual letters: k = posterior weakness and t = anterior tongue
- Atrophy of the gonue is likely LMN; Stiff pointed tongue = UMN
20
Q
Know the Motor strength levels
A
- 0 = no contraction
- 1 = visible muscle twitch but no movement of the joint
- 2 = weak contraction insufficient to overcome gravity
- 3 = weak contraction able to overcome gravity but no additional resistance
- 4 = weak contraction able to overcome some resistance but not full resistance
- 5 = normal; able to overcome full resistance
21
Q
describe the reflex grading system
A
- 0 = absent (LMN)
- 1 = reduced (hypoactive)
- 2 = normal
- 3 = increased (hyperactive)
- 4 = clonus (UMN)
22
Q
Define Babinski sign
A
- Plantar response
- blunt narrow surface (handle of reflex hammer) stroke sole of patients foot along lateral edge to base of toes in a J stroke
- normal response is to thave all toes flex
- abnormal response (after 2) is extension of great toe and fanning out of other toes out (outgoing or downgoing)
23
Q
What are the expected findings of a sensory exam
A
- minimal differences bilaterally
- accurate interpretation of sensation (hot vs cold, sharp vs dull)
- correct discrimination of side of body (left vs right)
- accurate location of sensations
24
Q
define Graphesthesia
A
- carried on posterior columns to cortex
- eyes closed, draw a letter or number on patients palm with dull object (capped pen)
- Positive test = problem in posterior columns or sensory cortex, specifically parietal lobe
25
define stereognosis
- carried on posterior columns to cortex
- eyes closed, place familiar object in hand to feel and manipulate
- repeat with both hands
- POSITIVE = called tactile agnosia = inability to recognize objects by touch, from parietal lobe or posterior column lesion
26
define two point discrimination
- carried on posterior columns to sensory cortex
- eyes closed, alternately touch patient with one point or two simultaneously
- determine distane at which pt can no longer feel the two points (varies by part of body)
27
define monofilament test
- evaluates fine touch sensory perception of the foot; used in patients with diabetes mellitus to screen for peripheral neuropathy
- eyes closed, test ten sites each foot in random pattern, each tests last 1.5 secs, varied interval, aoid callused areas
- Abnormal = not able to feel 7/10 sites may indicate peripheral neuropathy
28
define Finger-to-nose test
- pt seated with eyes open
- position your finger 18 inches away
- pt touches their index finger to their nose and then to your finger. Move your finger several times and make sure that full arm extension (with promation and supination)
- POSITIVE = misjudgement of the range of movement is called dysmetria and may indicate cerebellar disease
29
finger-nose-finger test
- eyes closed, arms extended out to both sides
- pt touch their nose with index finger of each hand, one hand at a time. Ask pt to increase speed
- POSTIVE = misjudge the distance (dysmetria) and overshoot and hit their face (hypermetria) or undershoot their nose (hypometria)
30
Heel to shin test
- Evaluates cerebellar function of IPSILATERAL SIDE through accuracy of movements of lower extremity
- Pt runs heel of one foot up and down the shin of the OPPOSITE LEG, repeat with other side (do not use arch of foot)
- POSITIVE = abnormal movements, could be part of dysmetria, tremors or ataxia
31
How to test gait and balance
- gait observation
- tandem gait (heal-toe walking)
- ability to walk on heels and toes
- promator drift
\* look for foot drop \*
32
describe promator drift test
- tests for lesions of corticospinal tract and proprioception (also proximal mm)
- have patient stand for 20-30 secs with both arms straight forward
- palms up, eyes closed
- keep arms still while you tap them downward
- hands drift downward, pt can't maintain supination and extension
\*\* REFLECTS UMN LESION\*\*
33
describe meningeal signs
- Nuchal regidity = inability to flex neck with testing
- Brudzinksi sign = with pt supid, passive flexion of the neck causes involuntary flexion of hips
- Kernig's sign = with pt supid and hip and knee flexed; attempt to passive extend the knee is painful and cannot be done
34
What is affected by B12 deficiency
- Dorsal columns are affected by B12 and syphilis
- control proprioception and vibration
35
sensory exam of superficial pain and superficial touch
SUPERFICIAL PAIN
- part of PNS, carried by small fibers of spinothalamic test
- used dull and sharp
SUPERFICIAL TOUCH
- part of PNS and carried by spinothalamic tract and posterior columns by modulated mylinated fibers
- used cotton wisp or finger (light strokes)
36
describe Romberg test
- NOT test for cerebellar function but tests PROPRIOCEPTION (signals from joint to tell you where you are in space)
- have pt stand with feet close together, arms at side, if patient is steady have them close eyes and maintain position for 30-60 seconds with feet together and eyes closed
- Loss of balance with eyes open and closed is suggestive of cerebellar disease
37
Hop test
- Hop in place on one foot and then the other for 5 secs each
- instability if pt needs to cintunally touch the floor with other foot to maintain balance
38
define gait and balance test
- observe gait sequence and length of stride (without shoes)
- observe posture of trunks
- observe arm movements
- Abnormal = could be cerebellar disease, vestibular disease, proprioception problem, footdrop from peripehral disease or basal ganglia problem
- PARKINSONS = bradykinesia and have trouble starting and stoping moements (forward pulsion or retropulsion) (fall to side of lesion)
