Three Flashcards
(36 cards)
What are 5 questions that should be asked as part of the clinical method of neurology?
- In every patient there is the inherent question, is the nervous system functioning normally or is it sick?
- If the nervous system is impaired, in what portion (or portions) is the pathology localized?
- Wherever the pathology is located, what is the tempo of the underlying pathophysiologic process?
- What diagnostic studies verify the clinical formulation?
- What treatment is appropriate?
What are cardinal manifestations of neurological disorders?
- Alterations in Consciousness
- Abnormalities of Intellect and Behavior
- Impaired Motility
- Disorders of Stance and Gait
- Pain
- Disorders of Special Senses
- Abnormal Eye Movements and Pupillary Reactions
- Changes in Sleep
- Autonomic Disorders
What are two ways that alterations in consciousness can occur? What are some possible results?
- Alterations in Consciousness
Temporary changes in consciousness occur with reduction in blood flow, producing syncope, or a neuronal discharge, commonly manifested by a focal or generalized seizure. A protracted alteration in the metabolic function of the reticular activating system and/or its cerebral connections results in altered consciousness that ranges from lethargy to stupor to coma.
What are some examples of abnormalities of intellect and behavior?
Disturbed thinking (e.g., poor logic, confusion), altered affect and loss of higher cortical functions (e.g., memory, language, calculations, judgment, abstract thinking, etc.) reflect both diffuse and focal disease in the cerebral cortex.
Examples of altered behavior include the irritability of hypoxia, the apathy of dementia or sudden alteration in ordinary activity, as occurs with an absence or partial complex seizure.
What are some examples of impaired motility?
Disturbances in motility are manifest by weakness, altered tone, changes in muscle bulk or disorders in movement. The distribution of the weakness (e.g.,
paraparesis versus hemiparesis), the type of altered tone, the size of the muscle and the form of abnormal movements (e.g., myoclonic jerks, chorea, hemiballismus, tremor) are helpful in localizing the pathologic disturbance.
What are some examples of disorders of stance and gait?
Alterations in the posture of the upright stance are evident in a tilt, stoop or widened base and may characterize a neurologic disturbance. Similarly, careful observation of an altered gait may show instability, festination, altered tone in one leg, high steppage, waddling or tottering and give clues to the underlying neurologic diagnosis.
What are 6 important aspects of pain that characterize its pathogenesis? What are 3 examples of altered sensation and what do they usually signal?
Pain is a fundamental product of altered sensation due to functional or structural disturbances. Its mode of onset, location, duration, severity, character and frequency characterize its pathogenesis. Headache, nerve root pain and
paravertebral pain have important implications to neurologic disease. Altered sensation such as paresthesias (tingling), hyperpathia (excessive sensitivity) and causalgia (burning) signal a neurologic, often peripheral, disturbance.
What are some examples of disorders of special sense?
Loss of a special sense or alteration of that sense, e.g., the foul smell of olfactory hallucinations, bright flashes (photopsias), ringing (tinnitus) and spinning
sensation (vertigo) implicate a disturbance along the anatomic pathway for that special sense.
What are some examples of abnormal eye movement and pupillary responses?
Paralysis of eye movements includes disturbance in horizontal or vertical conjugate gaze. Ocular nerve palsies produce disparate eye movements. The
resulting misalignment of the ocular globes causes the patient to see double images (diplopia). Disrupted parasympathetic innervation to the sphincter pupillae muscle or sympathetic supply to the dilator pupillae muscle produces changes in the pupil’s size and in the reaction to light and near fixation with respect to the parasympathetic pathway.
What are 3 specific examples of abnormal eye movement and pupillary response disorders? What are their symptoms?
Oculomotor nerve palsy: mydriasis, ptosis, down and out position
Abducens nerve palsy: eye will not look outwards (right eye won’t look right)
Horners syndrome: Pupil doesn’t dilate in low light.
What are some examples of changes in sleep?
Lack of sleep, excessive sleep and altered sleep (e.g., sleep paralysis, somnambulism, sleep apnea, enuresis) all result from dysfunction mediated within
the central nervous system.
What are some examples of autonomic disorders?
Common disorders of the autonomic nervous system are expressed in the inability to regulate blood pressure during orthostasis, maintain control of the bladder, attain or sustain sexual intercourse due to failure in penile erection, or regulate water metabolism or the appetite.
What are the nine steps of a neurological examination?
A. Mental Status and Higher Cerebral Function B. Cranial Nerves C. Motor D. Sensation E. Coordination: F. Reflexes G. Autonomic Function H. Head, Neck and Spine I. Palpable or Tender Peripheral Nerves
What are 12 steps for testing mental status and higher cerebral function?
- Appearance and behavior
- Level of consciousness
- Orientation - time, place, person
- Memory
- immediate: retention of sequential digits forward or backward
- recent: recall of known items or events
- past: recollection of events in childhood, school, marriage, work - General information (local and world events)
- Calculations (double digit addition and subtraction; making change
- Ability to abstract: interpretation of proverbs; similarities
- Judgment and insight
- Mood
- Hallucinations and delusions
- Speech
a. Articulation, phonation, volume; Dysarthric features: slurring, disorders of pitch and tonal inflection
b. Fluency (rate of speech) and correctness of spontaneous speech
c. Repetition: syllables, words, phrases
d. Comprehension of spoken language (one, two or three stage motor commands)
e. Naming of objects and their parts
f. Reading
g. Writing - Special tests for apraxias and agnosias
How are the 12 cranial nerves examined for function?
I. Smell (tobacco, cloves, etc.)
II. Visual acuity and visual fields (including double simultaneous stimulation)
III. Pupil size and reaction to light and accommodation
III, IV, VI. Eye movements: cardinal directions of gaze; convergence
V. Strength and bulk of masseter, temporalis, pterygoid muscles; Sensation over three divisions (trigeminal) of the face; Corneal reflex; Jaw jerk
VII. Facial movements: eye closing, grimace, smile
VIII. Examination of hearing:
Otoscopic examination
Recognition of whispered words or quiet sounds
Weber and Rinne tests with 512 Hz tuning fork
Examination of the vestibular system
Caloric testing.
Positional changes (inversion) of the head to induce nystagmus and vertigo
IX,X. Palatal movement, Swallowing, Phonation, Gag reflex, Laryngoscopic examination - indirect for cord movement
XI. Strength and bulk of sternomastoid and trapezius muscles
XII. Inspection of tongue for atrophy, fasciculations
Protrusion of tongue in midline and laterally
What are 5 ways to test motor ability in a neuro exam?
- Bulk: Note wasting or hypertrophy
- Tone - by passive movement of the limb and review of posture
- Power: Major functional groups about each joint, skilled movements, including fine motor movements
- Involuntary movements: tremor, myoclonus, chorea, dystonia,
- Posture
What are 10 ways to test sensation in a neuro exam?
- Pinprick
- Temperature
- Touch
- Vibration
- Joint position
- Two-point discrimination
- Localization of touch
- Number writing on palm or digit
- Appreciation of texture, size, shape (for astereognosis)
- Double simultaneous stimuli (for extinction)
Rapid movements: side-to-side. Lingual sounds (“la, la, la”)
How do you test coordination in a neuro exam?
finger-to-nose, heel-to-shin and knee, rapid alternating movements
Station: Normal stance and Romberg
Gait: Normal walk and tandem
How do you check reflexes in a neuro exam?
- Tendon jerks: jaw, biceps, triceps, brachioradialis, finger flexors, knee, ankle, biceps femoris, semimembranosus
- Superficial: abdominal, cremasteric, anal, bulbocavernosus
- Pathologic: suck, grasp, avoiding, plantar (Babinski) response
What are 5 ways to check autonomic function in a neuro exam?
- Sweating, piloerection
- Skin temperature
- Bowel, bladder and sexual function
- Vasopressor and cardioacceleratory responses
- Blood pressure and pulse (supine, sitting, standing)
What are 4 things that should be check in the head, neck,, and spine in a neuro exam?
- Signs of meningeal irritation
Nuchal rigidity, Kernig’s sign, Brudzinski’s sign - Cranium
Size and shape
Signs of trauma, e.g., ecchymosis about orbit or over mastoid eminence (Battle’s sign)
Tenderness - Spine: configuration; tenderness
- Cerebral blood vessels
Pulsation: carotid, temporal, subclavian, angular arteries
Blood pressure in each arm
Bruits - carotid, subclavian, suboccipital, temporal
What are 3 nerves that should be checked for palpability or tenderness in a neuro exam?
ulnar, peroneal, mental
What are the symptoms of primary muscle disorder?
The symptoms are usually bilateral, symmetrical and proximal, being distributed in limb-girdle muscles of the shoulders and hips. In many forms of muscle disease the sternocleidomastoids are weak. Muscles may be thin and hypotonic.
Reflexes are usually normal except when muscles are severely wasted.
What are the symptoms of a peripheral nerve disorder?
The signs of weakness and sensory loss are limited to the territory of the affected nerve whose trunk may be tender or thickened. Loss of the tendon reflex and of muscle mass (wasting) may be present, too. Multiple peripheral nerves are involved simultaneously or in sequence.
