Small pupil - Opioids - Horner's

Neurology Exam Flashcards by Amy Carter

Structure? Cranial Nerves

General Inspection
5Qs: sight, smell, hearing, swallow, speech/ dry eyes/ mouth
4 eyes: visual fields, pupils (direct, consensual, swinging), fundoscopy, eye movements
3 face: raise eye brows, squeeze eyes shut, show teeth - against resistance
2 mouth: uvula, tongue

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Structure? Limbs

Inspection - wasting, fasciculation, tremor, myoclonic jerks, deformity/ posture, pronator drift 
Tone, clonus 
Power 
Reflexes 
Coordination 
Sensation- pin prick, vibration
Gait
Romberg's

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Power Upper Limb Nerve Roots

Shoulder abduction C5
Elbow flexion C5/6 and elbow extension C7
Wrist flexion C7 and wrist extension C7
Finger extension C7, flexion C8 and abduction T1
Thumb abduction T1

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Power Lower Limb Nerve Roots

Hip flexion L1/2/3 and extension L5/ S1
Knee flexion L5/S1 and extension L3/4
Ankle dorsiflexion L4/L5 and plantarflexion S1/S2

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Reflexes Upper Limb Nerve Roots

Biceps C5
Supinator C5/6
Triceps C7

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Reflexes Lower Limb Nerve Roots

Knee L3/4
Ankle S1/2
Plantar - UMN lesion

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Sensation Upper Limb Nerve Roots

Shoulder C5
Thenar eminence C6
Middle finger C7 
Little finger C8
Medial arm T1

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Sensation Lower Limb Nerve Roots

ASIS L1 
Lateral upper thigh L2
Knee upper L3
Medial shin L4 
Lateral shin L5 
Little toe S1
Back of leg S2

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Eye signs

Ptosis
Miosis 
Mydriasis 
Kayser Fleischer Rings 
Argyll Robertson pupil 
Holme- Adie pupil 
RAPD
External ophthalmoplegia 
CN III, IV, VI nerves
Papilloedema

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Ptosis

Unilateral: 
- CNIII palsy 
- Horner's syndrome 
Bilateral 
- Myasthenia gravis 
- Muscular Dystrophies 
- Mitochondrial Disorders

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Miosis

Small pupil

Opioids
Horner’s

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Kayser Fleischer Rings

Copper deposition

- Wilson’s disease

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Argyll- Robertson Pupil

Small, irregular pupils
No response to light, response to accommodation
- Diabetes
- Syphilis

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Holme- Adie Pupil

Dilated pupil
Benign
Once constricted remains small for a long time

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Relative Afferent Pupillary Defect

'Marcus Gunn Pupil' 
Swinging light test 
Lesion anterior to optic chiasm 
Affected eye dilates when light shone on it 
- Retinal detachment 
- Optic nerve e.g. optic neuritis

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Mydriasis

CNIII palsy
Holmes Adie
Traumatic iridoplegia
Pheochromocytoma
Congenital
Drugs e.g. sympathomimetic, topical mydriatics (tropicamide), anticholinergics

External Ophthalmoplegia

Mitochondrial disease
Myasthenia Gravis
LEMS
## Miller Fisher Syndrome

CN III palsy

Eye down and out

Associated with mydriasis, ptosis

CN IV palsy

Nasal upshoot 
Superior oblique (eye down and rotated in)

CN VI palsy

Can't abduct 
Lateral rectus (abduction)

Papilloedema

Raised intracranial pressure

Increased CSF: hydrocephalus
Haematoma
Aneurysm
Tumour
Infection: meningitis, encephalitis
CVST
Idiopathic

CN VII Palsy

Paralysis of facial muscles

LMN - Bell’s Palsy, no sparing of the forehead

Mouth

Uvula
- deviates away from lesion 
- vagus nerve
Tongue 
- deviates towards lesion 
- hypoglossal nerve
- fasciculations

Pronator Drift

Down and pronates
- Muscular weakness due to UMN lesion
Up and pronates
- Cerebellar disease

Cerebellar Ataxia

``` Intention tremor Dysmetria- past pointing Dysdiadochokinesia Ataxia Slurred/ scanning speech ```

Sensory Ataxia

Loss of proprioception = sensory ataxia

Parkinsonism

Bradykinesia Rigidity Tremor (Postural instability)

Bradykinesia

Pincers | Foot tapping

Tremor Parkinsonism

Unilateral Pill rolling Resting Count down from 10 - distraction

Rigidity

Cogwheel rigidity

Parkinson's Gait

Reduced arm swing Shuffling Freezing Stooped

Essential Tremor

Action tremor Family history Bilateral

Chorea

``` Dance like involuntary movements- hyperkinetic Athetosis and ballismus Causes - Genetic: Huntington's - Drug induced: Phenothiazines, L dopa - Immune mediated: SLE, post infectious - Infectious: HIV, syphillis - Structural: stroke, brain tumours - Metabolic/ toxic: hyperglucaemia, CO poisoning ```

Dystonia

Involuntary co-contraction of agonist and antagonist muscles Abnormal posturing

Parkinson's Assessment

EOB: walking aids, hypomimia, tremor Tremor: resting, worse on distraction (count back from 10), postural (hands outstretched), action (perform an action e.g. take pen out of hand), finger to nose, Bradykinesia: rapid pincers - reduction in speed, cadence and amplitude Rigidity: increase tone, cogwheel (if not increased, ask patient to perform task with other limb (Power, tone reflexes all normal) Gait: stooped posture, difficulty initiating movement, short, shuffling steps, reduced/ absent arm swing, festination, difficulty turning, freezing phenomenon Eye movements: vertical gaze palsy (progressive supranuclear palsy) and nystagmus (cerebellar pathology) Speech: Dysarthria or staccato (cerebellar), baby hippopotamus, hypophonia Other: postural BP, micrographia, cognition

Power MRC 0-5`

``` 0 No contraction 1 Twitch 2 No gravity 3 Against gravity 4 Reduced power against resistance 5 Normal Power ```