Neuroscience and Neurology Examinations Flashcards

Question

Where to place tuning fork? A. Upper limbs B. Lower limbs

Answer 1

A. Upper limbs - Distal or proximal IPJ - MCPJ - Radial or ulnar styloids - Olecranon - Clavicle B. Lower limbs - IPJ of big toe - Medial or lateral malleoli of ankle - ASIS

Answer 2

1. Spastic / flaccid 2. Distribution - monoparesis, hemiparesis, paraparesis, tetraparesis 3. Site - left/right ; upper or lower limb 4. Upper or lower motor neuron signs 4A. Elaborate reason - tone, reflexes 5. Chronicity - UMNL: contracture - LMNL: wasting 6. Functional status

Answer 3

Both must be full inspection of UL and LL - Why? Wasted thighs + shoulder - proximal myopathy Wasted fingers and distal muscles - distal myopathy Expose: - Upper limbs - Lower limbs - Upper back - Neck - Head

Answer 4

Exposure: Remove shirt and also expose lower limbs Inspection: surroundings for aids; patient's head, neck, shoulder, back, arms for wasting, scars, abnormalities 4 manoeuvers: pronator drift, wrist hyperextension, sustained 3 seconds myotonic grips, fasciculations - Pronator drift fully supinated and straight, fully adduct fingers - Wrist and finger hyperextension - wrist drop - Grip myotonic sustained 3 seconds clench then open - Fasciculations (controversial) Tone Reflexes Power Sensation - touch (dorsal column) ; pain (spinothalamic) Proprioception: thumb - ask patient to close eyes, stabilize joints Vibration with 128Hz tuning fork (dorsal column) Coordination: past pointing, dysdiadochokinesia

Answer 5

Varying speed - Slow passive movement first (to elicit hypotonia) - Then fast movement (to elicit Parkinsonism) Full range of motion Single joint 1. Passive elbow flexion/extension 2. Passive wrist flexion/extension 3. Passive pronation/supination - pronator teres - Elbow at 90 degree - Supinate quickly, pronate slowly for supinator catch

Answer 6

Both arms in rested position, 90 degrees Hit at right speed, let tendon hammer drop, do not pull back If correctly position does not even need to move to opposite side 1. Biceps reflex C5/C6 2. Triceps reflex C6/C7 3. Brachioradialis reflex C5/C6- use own thumb to isolate patient's thumb

Answer 7

Shoulder abduction Shoulder adduction - kiap, don't let me pull Elbow flexion and extension - 90 degree, stabilise elbow with the other hand (prevents use of latissimus dorsi) Wrist flexion and extension - No need like for like with wrist, just use ulnar aspect of hand Finger flexion (do Jendrassik with patient) Finger abduction Finger adduction - pull with paper Thumb abduction/adduction

Answer 8

**Mainly pain sensation for spinothalamic_** Deltoid regimental badge - axillary nerve / C5 Arm lateral - C5 + radial Forearm lateral - C6 + musculocutaneous Thumb - C6 + median Middle finger - C7 + half median/ulnar Little finger - C8 + ulnar Forearm median - C8 + cutaneous Arm medial - T1 **If proprioception/vibration impaired, proceed to test fine touch - DCML** Do not stroke with cotton bud! - Stroking activates nociceptors and itch -> becomes testing for spinothalamic tract

Answer 9

Touch your nose tip, then touch my finger tip - Jerking and hesitancy - Past pointing - Depth perception Both touching finger tip and returning to nose tip are equally important cerebellar signs!

Answer 10

Exposure: Remove pants ideally - inguinal to toes and shirt Inspection: - Surroundings for walking aids, catheter; - LL: wasting, contractures, scars, abnormalities, asymmetry (short, wasted), clawed toes - Back: scars and tufts of hair - Neck, shoulder, arms for wasting, fasciculation, abnormal posture - Face: facial droop, ptosis Manoeuvers: dorsiflexion of both ankles Fasciculations Tone Reflexes Myoclonus - 3 or more beats Babinski Power Sensation - touch (dorsal column) ; pain (spinothalamic) Coordination: heel shin test Proprioception: big toe Vibration with 128Hz tuning fork (dorsal column) Romberg and Gait

Answer 11

Roll thighs - Move slowly then fast for rigidity Passive knee flexion/extension - If legs go off the bed - spasticity (UMN) - if legs draggy - flaccid (LMN) Do not test myoclonus yet at this point

Answer 12

1. Knee jerk: Lift knee and relax to tap knee 2. Ankle jerk: Bend knee to test ankle 3. Plantar reflex: stroke for 3-5 seconds from sole to 1st MTPJ (L shape) (this is the blunt end of stick, I will scratch bottom of your feet and will be uncomfortable) - Babinski negative: S1 loops back to S1 - downgoing - Babinski positive: slow extension - spinal cord disorder disinhibition, S1 stimulus activates L4, L5 - Withdrawal: fast extension **Use the term**: positive plantars or negative plantars. Forgo use of Babinski term 4. Myoclonus - at least 3 or more beats - Bend the knee to relax the gastrocnemius - Perform if DTR 2+, otherwise minimal value - Sustained: 5+ - Present but not sustained: 4+

Answer 13

1. Active lift whole LL up - can also see downdrift and ataxia if present 2. Hip flexion/extension - push leg up or down against hand - Stabilise ASIS and lateral hip 3. Hip abduction/adduction - only in foot drop (do not force open or close the thighs - rude!) - Turn to lateral side - Press lateral surface of gluteus region for gluteus minimus - Press down over lateral thigh 4. Hip internal/external rotation - Lift leg up, bend knee 90 degree, passive internal/external rotate then ask to push against resistance 5. Knee flexion/extension - in neutral position (90 degree) 6. Ankle dorsiflexion and eversion concurrently - Push against hand when dorsiflexed - Push Inversion for resistance 7. Ankle plantarflexion and inversion concurrently - Push against hand when plantarflexed - Push eversion for resistance 8. Toe flexion and extension

Answer 14

Perfect reference point: forehead - but hygiene issue Then test sternum - if equal, to use it as indirect reference point 1. Mid anterior thigh - L2 + femoral 2. Medial aspect of knee - L3 + femoral 3. Medial malleoli - L4 + saphenous branch of femoral nerve 4. Distal lateral malleoli - L5 + superficial peroneal 5. 1st dorsal webspace - L5 + deep peroneal 6. Lateral side of foot - S1 + tibial nerve (Try to avoid soles (S1) - cleanliness issue) Peripheral neuropathy Distal to proximal (x1 medial, x1 lateral) to obtain level of sensation (over dorsum of foot) (Avoid soles/plantars - cleanliness issue)

Answer 15

Proprioception: first big toe Vibration: 128Hz tuning fork 1. Big toe 2. Ankle joint 3. Patellar 4. ASIS

Answer 16

3 point triangular movement - slide heel down to shin - lift leg upwards (no need finger or palm as reference - most patients will likely miss) - downward back to anterior knee Observe for jerky or wavy heel from knee to shin

Answer 17

Test for latent dysequilibrium Sit patient to side, check no truncal ataxia first Then stand patient Both arms hugging Eyes closed Test for tabes dorsalis - sensory ataxia - Dysequilibium on eyes closed Do not perform in cerebellar ataxia - patient will definitely fall -> dangerous!

Answer 18

1. Spastic gait 2. High stepping gait (foot drop) 3. Waddling gait (proximal weakness) 4. Parkinsonism shuffling gait 5. Ataxic gait + tandem gait

Answer 19

Flexor digitorum profundus - Little finger IPJ 1st dorsal interrosei wasting Dorsal sensory branch Bilateral ulnar neuropathy - mononeuritis multiplex Need to do blood panel: HbA1c, ESR, ANCA, HIV, Syphilis, PTB Got 1 case suay - bilateral ulnar tunnel syndrome with surgical scars Ix: NCS - confirm, nature (axonal vs demyelinating vs focal) MRI arm - compressive lesion Refer HRM or ortho

Answer 20

RN comes out together with axillary nerve - Check deltoid bulk 3 proximal Sensory nerve over lateral arm, brachioradialis Triceps weakness Extensor carpi radialis longus (ECRL) Deep and superficial nerve superficial - Dorsum hand numbness, snuffbox area Deep - pierce supinator muscle > PIN syndrome: finger and wrist drop - Test index finger

Answer 21

Exposure and Inspection CN1 - ask for loss of smell CN 2 - gross visual acuity and field, pupil constriction, light reflex CN 3, 4, 6 - H test for EOM, saccades The rest either in CN sequence (avoid missing out) or domains (demonstrates finesse) Motor: CN 7, 5, 9, 10, 12 then 11 Sensory: CN 5 and 8 in exam (7, 9, 10 usually not tested) Speech: Majulah Singapura - Singapore British Constitution - UK Perpustakaan - Malaysia Screen for long tract deficit (brainstem deficit): Pronator drift Dysmetria

Answer 22

Seated up, fully expose face, neck, INCLUDING shoulders and upper limbs Face - facial dysmorphism, asymmetry, blepharoptosis, strabismus, abnormal posture (torticollis) Look at trapezius wasting - spinal accessory nerve Look at hands and fingers - wasting, Horners Look behind the auricles and SPLIT the hairs - Posterior cranial fossa scars - Ear abnormalities - otorrhoea, vesicles Look at surroundings for walking aids

Answer 23

CN1: smell - olfactory nerve endings from upper part of nasal mucosa to CNS **Test:** ask the patient - do you notice any change or loss in sense of smell or taste Formal testing with coffee powder or test batteries usually not done

Answer 24

_1. Visual acuity_ - Test each eyes individually - Can you see the numbers? use small numbers (1 to 3) (Do not use 5) - Mini Snellen’s chart 3 metres away (usually not done in PACES anymore) _2. Colour_ - Big red ball - (usually not done - quite pointless, only testing 1 colour) _3. Visual field_ - Close 1 eye with hand, look at my eye (we may or may not need to close our own eye) - Use big red ball - From the side of quadrants all the way to the centre, ask: 1. Let me know when it appears 2. Inform me if disapepars _4. Pupillary light reflex and RAPD_ (See subsequent cards)

Answer 25

Tested in **dark room** with **yellow light** Stand at patient's side and ask him to look far (avoid accommodation reflex) 1. Anisocoria - Shine from far away to look at both pupils - equal or unequal (anisocoria) 2. Pupillary constriction - Shine from the side then move closer, observe constriction

Answer 26

_Consensual light reflex_ - Swing 1 second in oblique manner (NOT directly in front of patient’s eye) - RAPD is tested with 1 torch - real PACES only 1 torch provided -When swing to the next eye, eye will dilate first (from previous consensual constriction) then re-constrict back _If RAPD positive:_ - Affected eye - no constriction - Swinging eye to unaffected - no dilatation, only constriction - Swing back to affected eye - from constrict to dilatation (from consensual reflex constriction), no re-constriction - Offer to do **fundoscopy** on both sides

Answer 27

_CN3 - occulomotor nerve_ - Medial rectus - adduction - Superior rectus - upgaze - Inferior rectus - downgaze - Inferior oblique - upward abduction - Levator palpebrae superioris - elevates superior eyelid - Ciliary ganglion - pupillary constriction - Ciliary muscle - lens accommodation Origin: - Oculomotor nucleus (midbrain) - EOM - Erdinger-Westpal nucleus - constriction and accommodation - No decussation Deficit: 1. Ipsilateral downward outward deviation - Unopposed CN4 and CN6 action 2. Ipsilateral ptosis 3. Ipsilateral mydriasis

Answer 28

_CN4 - trochlear nerve (SO4)_ - Superior oblique - downgaze abduction Origin and course: - Trochlear nucleus (midbrain), decussate at midbrain-pons junction, exits from posterior - Superior oblique is hooked around a trochlear Deficit: 1. Ipsilateral upwards outwards deviation 2. Diplopia 3. Compensatory head tilt

Answer 29

_CN6 - abducens nerve (LR6)_ - Lateral rectus - abduction Origin and course: - Abducens nucleus (pons) - No decussation for main pathway - Exits at pons-medulla junction - Alternate pathway: medial longitudinal fasciculus - Decussate to control contralateral medial rectus muscle - Coordinates eye movements (eg: LE abduct, RE controlled to adduct) Deficit: 1. Ipsilateral adduction deviation - Unopposed medial rectus muscle 2. Diplopia

Answer 30

_Slow pursuit_ - Double H - Adequate distance - Not too fast, or else pursuit will be broken - Hold at extreme ends to look for nystagmus - Change hand when going the other side - Red pin held horizontally

Answer 31

1. Horizontal - Red ball held next to you 1A. Vertical - Red ball held above you 2. Ask patient to alternate looking at red ball and your nose both horizontal and vertical Vertical saccade - PSP Horizontal saccade - INO

Answer 32

_Motor_ V3 - masseters, temporalis muscle - Bite down and clench jaw strongly - Palpate temporalis and masseter muscle _Sensory_ Test with cotton bud as default: pontine nucleus Test with pinprick: spinal nucleus, medullary lesion V1 - both sides of forehead V2 - lateral to the nose (do not test over maxilla as there is overlap between V2 and V3) V3 - both sides of jaw

Answer 33

1. Forehead asymmetry - Head down, Look up, wrinkle forehead 2. Orbicularis oculi weakness - Squeeze eyes shut, bury eyelashes - Test power of 1 eye at a time with both index fingers 3. Facial asymmetry - Observe for drooping - Puff cheeks - Smile, show your lower teeth - platysmal asmmyetry 4. Sensation - Two-thirds of tongue (not usually tested in PACES) - Stapedius muscle (hearing) (hard to test/determine bedside) - Concha of the ears (not tested in PACES) 5. Parasympathetic - Tear production (lacrimal gland) - Salivary production (submandibular and sublingual gland)

Answer 34

Tested with 512Hz tuning fork Tuning fork with both prongs parallel (not perpendicular) to the ear Apply counter force for bone conduction - Top of head when doing Rinne - Back of head when doing Weber _Normal_ Rinne test: AC > BC Weber test: equal CDHL: Rinne BC > AC, Weber affected louder SNHL: Rinne AC > BC, Weber normal louder

Answer 35

1. Palatal and uvula deviation - Open mouth, say "ahhhh" 2. Gag reflex (not usually tested in PACES) - Tongue depressor gently and deliberately touch pharyngeal wall or either side tonsillar pillars (test both sides) - Patient will gag (elevate and constrict phayngeal muscles, elevate soft palate, retract tongue)

Answer 36

1. Sternocleidomastoid muscle - Turn your head to one side then the other, palpate SCM muscles 2. Shoulder shrug - trapezius - Shrug shoulders, push down against them

Answer 37

1. Tongue deviation - Stick out your tongue 2. Tongue weakness - Push tongue against cheeks

Answer 38

1. Pronator drift 2. Dysmetria 3. Hypertonia 4. Hyperreflexia

Neuroscience and Neurology Examinations Flashcards

(62 cards)