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Phase 2B - History and Examinations > Neurological > Flashcards

Flashcards in Neurological Deck (50):
1

Hx:
Site:

Ask Pt to point. Unilateral / bilateral?

2

Hx:
Onset:

Sudden or gradual? Thunderclap?

3

Hx:
Character:

Throbbing? Like a tight band?

4

Hx:
Radiation:

Does the pain radiate?

5

Hx:
Associated Sxs:

Nausea / vomiting, altered GCS, rash, pyrexia, neck stiffness, photophobia, visual loss, blurred vision, aura, tender scalp, malaise, rhinorrhoea/lacrimation?

6

Hx:
Timing:

Constant / intermittent? Single / recurrent? Duration? Worse at certain times of day / month / year?

7

Hx:
Exacerbating factors:

Noise, stress, bending, coughing, sneezing, blowing nose, eating, combing hair, bright / flashing lights, certain foods / drugs, dehydration

8

Hx:
Relieving factors:

Analgesia, dark environment, rest

9

Hx:
Severity:

Scale 1-10

10

Hx altered consciousness - pay attention to:

Onset
Activity at the time?
How they felt before episode
Associated Sxs: dizziness, nausea, vertigo, aura, tachycardia, sweating, weakness, paraesthesia, slurred speech, headache, tongue biting, incontinence
Recovery time, amnesia / post-ictal Sxs
Previous episodes?
Was episode witnessed?

11

With neurological Sxs other than altered GCS - note course - is it...

Static
Progressive
Relapsing / remitting

12

Neuro Hx - PMH (RFs):

Head / spinal trauma
Metabolic / endocrine disorders e.g. DM
Cancer (mets?)
Epilepsy
HTN
AF

13

Neuro Hx - Drug Hx + allergies:

Anticonvulsants
Drugs that interact w/ anticonvulsants / lower seizure threshold
Anticoagulants + anti-platelet drugs
Analgesics
Anti-HTNs
Antidepressants
Insulin
Recreational drugs

14

Neuro Hx - Social Hx:

Alcohol consumption
Smoking
Recreational drugs
Occupation
Social activities / hobbies
Home circumstances, level of independence

15

Neuro Hx - FHx:

DM
Cerebral haemorrhage
CVD / stroke
IHD
Migraine

16

Neuro exam upper limbs:
At the beginning, ask:

Do you have any pain anywhere?
L / R handed

17

Neuro exam upper limbs:
Inspection:

Posture
Wasting
Tremor
Fasciculations
Involuntary movements

18

Neuro exam upper limbs:
Tone:

Passively move each joint
Is there normal, even resistance?
Hypertonia (spasticity / rigidity?)
Hypotonia?

19

Neuro exam upper limbs:
Power (against resistance):

Protonator drift (UMN lesion)
Shoulders: flexion, extension, abduction, adduction
Elbows: flexion, extension, pronation, supination
Wrists: flexion, extension
Fingers: flexion, extension, abduction
Thumb: palmar abduction (median), adduction (ulnar) and opposition (median)

20

Neuro exam upper limbs:
Reflexes:

Biceps
Triceps
Supinator / brachioradialis
Use reinforcement if needed (clench teeth)

21

Neuro exam upper limbs:
Co-ordination:

Finger to examiners finger then to own nose repeatedly
Finger to own nose w/ eyes closed
Fine movements e.g. piano playing / touch thumb to each fingertip on same hand rapidly
Dysdiadochokinesis

22

Neuro exam upper limbs:
Sensation:

Soft touch
Pain / pinprick (OSCE: describe only)
Temperature (OSCE: describe only)
Proprioception
Vibration
Cortical localisation - stereogenesis (identify key / coin placed in Pt's palm w/ eyes closed; 2 point discrimination; graphaesthesia

23

Neuro exam upper limbs:
Protonator drift:

Pt's arms are outstretched + supinated
Eyes are then closed
Pt is asked to keep arms still
Tap Pt's hands to provoke slight movement
Should automatically be corrected + arm position maintained
If one arm pronated + drifts down upon eye closure - contralateral UMN lesion

24

Neuro exam lower limbs:
Inspection:

Posture
Wasting
Tremor
Fasciculations
Involuntary movements

25

Neuro exam lower limbs:
Tone:

Passively move each joint
Is there normal, even resistance?
Hypertonia (spasticity / rigidity?)
Hypotonia
Check for ankle clonus (UMN lesion)

26

Neuro exam lower limbs:
Power (against resistance):

Hip: abduction, adduction, flexion, extension
Knee: flexion + extension
Ankle: dorsiflexion + plantarflexion
Big toe: dorsiflexion + plantarflexion

27

Neuro exam lower limbs:
Reflexes:

Knee
Ankle
Use reinforcement if needed (clench fingers)
Plantar reflex (Babinski response)

28

Neuro exam lower limbs:
Co-ordination:

Heel-shin test

29

Neuro exam lower limbs:
Sensation:

Soft touch
Pain / pinprick (OSCE: describe only)
Temperature (OSCE: describe only)
Proprioception
Vibration

30

Neuro exam lower limbs:
Romberg's test:

Pt stands w/ feet together, arms outstretched + hands supinated
If Pt can't do this w/ eyes open --> cerebellar lesion
If Pt can do this but rocks + sways when eyes closed --> loss of proprioception

31

Neuro exam lower limbs:
Hemiplegic gait:

Arm adducted at the shoulder, flexed elbow + wrist, leg extended + adducted at the hip, knee extended + ankle plantar-flexed
Pt lurches upper body towards unparalysed to elevate pelvis and swing the paralysed leg around
Plantar flexed foot scrapes along the ground

32

Neuro exam lower limbs:
Parkinsonian gait:

Gait is slow + shuffling
Stride length markedly decreased
Loss of arm swinging
Festinant gait: Pt takes increasingly rapid steps forward in order to maintain an upright posture

33

Neuro exam lower limbs:
Steppage gait:

Paralysis of dorsiflexors of ankle --> "drop-foot"
Pt flexes the knee and lifts the foot high to clear toes from the ground. As it is returned to the ground, there is a loud slapping noise
Unilateral drop-foot suggests a common peroneal nerve palsy or spinal lesion
Bilateral - generalised polyneuropathy

34

MRC grading of motor power:

5/5: movement against gravity with full power against resistance
4/5: movement against gravity but with reduced power against resistance
3/5: movement against gravity only without applied resistance
2/5: muscle contraction with active movement but only when gravity is eliminated
1/5: flicker of muscle contraction seen, no movement
0/5: no muscle contraction

35

Cranial nerve examination:
Firstly, inspect the Pt's head and neck, commenting on:

Scars
Neurofibromas
Facial asymmetry
Ptosis
Proptosis
Skew deviation of the eyes
Pupil inequality

36

Cranial nerve examination:
Olfactory nerve (I):

Only usually tested if Pt reports alteration in sense of smell
Olfactory testing bottles / easily recognisable scents e.g. soap / coffee
Test each nostril separately, occluding the contralteral nostril by compressing it w/ finger

37

Cranial nerve examination:
Optic nerve (II):

Test visual acuity - Snellen chart (wearing glasses if needed)
Test visual fields by confrontation (hand over 1 eye, bring object in at diagonals)
Test for inattention / visual extinction: hold fingers at periphery of Pt's field, move 1 finger at a time then both at same time. Will ignore 1 side if inattention
Test direct + consensual light reflexes: ask Pt to look straight ahead and bring light source from 1 side (so Pt doesn't focus + accommodate).
Test accommodation: focus on distant point and then focus on finger, approx 30cm from their nose - look for constriction of both pupils

38

Cranial nerve examination:
Oculomotor (III), Trochlear (IV), Abducens (VI):

Ask Pt to keep head still and follow finger with eyes
Trace large H and central I shape with finger, taking Pt's eyes to limit of gaze
Ask for diplopia
Observe for dysconjugate eye movements + nystagmus

39

Cranial nerve examination:
Trigeminal nerve (V):

Test sensation in skin supplied by opthalmic, maxillary + mandibular nerves. Initially, demonstrate stimulus to Pt on sternum. Ask Pt to close their eyes and apply stimulus to each devision of CN V. Ask Pt to indicate they can feel stimulus and symmetry

Test motor component: clench teeth, palpate contraction in masseter and temporalis muscles. Ask Pt to open mouth against resistance. Look for jaw deviation

40

Cranial nerve examination:
Facial nerve (VII):

Ask Pt to screw up eyes and not let them be opened
Puff cheeks
Raise eyebrows, purse lips and show teeth

41

Cranial nerve examination:
Vestibulocochlear nerve (VIII):

Cover the opposite ear and whisper a number - ask them to repeat. If an abnormality is expected, perform Rinnes and Weber's test to determine whether this is a sensory or conductive defecit

42

Cranial nerve examination:
Glossopharyngeal (IX) and vagus (X) nerves:

Ask Pt to open mouth wide and assess whether uvula is in the midline at rest
Ask Pt to say aah and note any asymmetry of movement
Uvula will deviate away from the side of a glossopharyngeal palsy
Ask whether Pt has any difficulty swallowing - gag reflex is unpleasant and shouldn't normally need to be performed
Ask Pt to cough - bovine (non-explosive) cough = vagal palsy
Note any hoarseness of the voice

43

Cranial nerve examination:
Accessory nerve (XI):

Test trapezius by asking Pt to shrug shoulders against resistance
Test power of sternocleidomastoids by asking the Pt to turn head against resistance
Palpate body of sternomastoid muscle with free hand whilst doing so

44

Hypoglossal nerve (XII):

Ask Pt to open mouth + observe tongue at rest for fasciculations
Ask them to protrude tongue + note any deviation
Deviation toward side of hypoglossal lesion
Ask Pt to push tongue into cheek against resistance of finger to assess power

45

Rinne's test:

Vibrating tuning fork held on mastoid
Then held near the EAM - sound should continue to be heard
Conductive hearing loss: bone conduction > air - sound isn't heard at EAM
Sensorineural hearing loss: both air + bone conduction are decreased by similar amount

46

Weber's test:

Vibrating tuning fork held against forehead at the midline
Vibrations are normally perceived equally in both ears as bone conduction is equal
In conductive hearing loss, sound is louder in abnormal ear than normal ear
In sensorineural hearing loss, sound appears louder in the normal ear
Sensitivity of the test increased by blocking EECs with fingers

47

Examination for signs of cerebellar dysfunction:
Speech:

Assess for dysarthria by asking Pt to say repeating letters e.g. C, C, C, C or L, L, L, L or tongue twisters e.g. Baby Hippopotamus

48

Examination for signs of cerebellar dysfunction:
Intention tremor + dysmetria

e.g. past pointing

49

Examination for signs of cerebellar dysfunction:
Nystagmus:

Coarse + slow, most noticeable on looking toward the sife of the lesion

50

Examination for signs of cerebellar dysfunction:
Dysdiadochokinesis:

Difficulty in controlling rate, rhythm + force of movement
Pt is abnormally slow + uncoordinated when attempting rapid hand movements e.g. alternately tapping the palm and dorsum of right hand onto back of left hand quickly