Week 13: Nervous System and Mental Health Flashcards Preview

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Flashcards in Week 13: Nervous System and Mental Health Deck (54)
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1

What are the five categories of the neurological exam?

  1. Mental status
  2. cranial nerve testing
  3. motor system
  4. sensory system
  5. reflexes

2

What are some common or concerning symptoms that the FNP should assess for as part of the neurological history?

  • Headache
  • Dizziness or lightheadedness
  • Weakness
  • Numbness or abnormal or absent sensation
  • Fainting and blacking out
  • Seizures
  • Tremors or involuntary movements
  • Confusion
  • Memory loss
  • Trouble speaking
  • Vision loss or double vision
  • Difficulty walking

3

What are some red flags associated with headaches?

  • Sudden onset thunderclap headache
  • Worst headache of my life
  • Headaches after 50
  • Headaches that increase by coughing or reoccur in the same position
  • Fever/stiff neck
  • Migraine

4

What are the modifiable risks for TIA/stroke?

  • HTN
  • diabetes
  • a.fib
  • dyslipidemia
  • smoking
  • physical inactivity
  • CKD
  • overweight
  • nutrition
  • alcohol use
  • carotid artery disease
  • sickle cell disease
  • sleep apnea

5

What does ABCD2 stand for and what does it indicate?

  • Age greater/equal to 60 years
  • blood pressure greater/equal to 140/90
  • clinical features of focal weakness or impaired speech without focal weakness
  • duration 10-59 minutes or greater/equal to 60 minutes and diabetes

 

Tool to predict stroke likelihood after TIA

6

What does the acronymn FAST stand for?

Stroke symptoms

  • Face drooping
  • arm weakness
  • speech difficulty
  • time to call

7

What history and exam findings are consistent with TIAs/strokes? (5) 

  • Sudden numbness or weakness of the face, arm or leg
  • Sudden confusion, trouble speaking or understanding
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness or loss of balance or coordination
  • Sudden severe headache

8

What are the vascular territories for strokes and the corresponding clinical findings? 

Occlusion of the middle cerebral artery: visual field cuts and contralateral hemiparesis and sensory deficits 

Occlusion of the left middle cerebral artery: aphasia 

Occlusion of the right middle cerebral artery: neglect or inattention to the opposite side of the body

9

What are dizziness, vertigo, presyncope and syncope? 

Dizziness: nonspecific term

Vertigo: spinning sensation within the patient or of the surroundings accompanied by nystagmus and ataxia

Presyncope: lightheaded or weak but fail to lose consciousness

Syncope: sudden but temporary loss of consciousness and postural tone from transient global hypoperfusion

10

What is weakness? What are some etiologies? What patterns should you identify about weakness? 

  • May mean fatigue, apathy, drowsiness or actual loss of strength
  • Etiologies: TIA, stroke, Guillain-Barre, ALS, injury of the NMJ, myopathies
  • Assessment: Time course and location, what parts of the body are involved
    • Proximal: parts of the body that are closer to the thorax
    • Distal: hands/feet
    • Symmetric: same areas on both sides of the body
    • Asymmetric: one sided

11

How do you test for discriminative sensations? What could abnormal findings indicate? 

  • Stereognosis: ability to identify an object by feeling it
    • Abnormal = astereognosis
    • Impaired: posterior column disease
  • Number identification: draw a number on the hand and ask them to identify it
    • Abnormal = graphesthesia
    • Impaired: lesion in the sensory cortex, posterior column disease
  • Point localization: touch a point on the skin, open eyes and point to the location touched
    • Impaired: sensory cortex impairment
  • Extinction: touch each arm individually, then simultaneously touch corresponding areas on both arms, ask where the patients feels your touch with each stimulus
    • Impaired: lesions in the cerebral hemisphere cause extinction of the contralateral side

12

What tests can be used to assess gait?

Observe: casual walk, walk on toes and on heels, walk heel to toe in a straight line

13

What does spastic hemiparesis look like on exam? What impairment is present?

  • Spastic hemiparesis - corticospinal tract lesions
    • affected arm is flexed, immobile, held close to the side with elbow, wrists and interphalangeal joints flexed
    • Affected leg extensors are spastic; ankles are plantar-flexed and inverted
    • Patients may drag toe, circle leg stiffly outward and forward or lean trunk to contralateral side to clear affected leg while walking

14

What does steppage gait look like on exam? What impairment is present?

  • Steppage gait - foot drop, secondary to peripheral nervous system disease
    • Drag the feet or lift them high
    • Cannot walk on heels
    • May involve one or both legs
    • Tibialis anterior and toe extensors are weak

15

What does cerebellar ataxia look like on exam? What impairment is present?

  • Cerebellar ataxia- disease of the cerebellum or associated tracts
    • Staggering and unsteady gait with feet wide apart and exaggerated difficulty on turns
    • Cannot stand steadily with feet together with eyes open or closed
    • Dysmetria, nystagmus and intention tremor may be present

16

What does scissors gait look like on exam? What impairment is present?

  • Scissors gait - spinal cord disease that causes spasticity
    • Stiff gait, advance each leg slowly and thighs cross forward on each other with each step
    • Short steps
    • Patients appear to be walking through water, may be compensating sway of the trunk

17

What does the Parkinsonian gait look like on exam? What impairment is present?

  • Parkinsonian gait - basal ganglia defects of Parkinson disease
    • Posture stooped with flexion of the head, arms, hips and knees
    • Slow to get started
    • Short and shuffling steps with involuntary hesitation (festination)
    • Arm swings decreased and patients turn around stiffly
    • Postural control is poor

18

What does sensory ataxia look like on exam? What impairment is present?

  • Sensory ataxia - polyneuropathy or posterior column damage
    • Unsteady gait, wide based
    • Throw their feet forward and outward and bring them down, first on the heels then on the toes
    • Watch the ground for guidance when walking
    • With eyes closed, patients cannot stand steadily with feet together (positive Romberg sign), staggering gait worsens

19

What are tests of coordination? What do abnormal findings indicate? 

  • Rapid alternating movements: rapid alternating arm movements, rapid finger tapping
  • Point to point movements: finger to nose test, heel to shin test
  • Abnormal findings
    • Ataxia = loss of control of voluntary movements
    • Cerebellar disease = nystagmus, dysarthria, hypotonia, ataxia
      • Rapid alternating movements will be slow, irregular and clumsy (dysdiadochokinesis)
      • Finger tapping is imprecise with irregular rhythm
      • Finger to point movements will be clumsy, unsteady and inappropriately variable in speed, force and direction
    • Slow and low amplitude in finger tapping test may indicate upper motor neuron weakness and basal ganglia diseas

20

How would the FNP assess for diabetic neuropathy?

  • Pin-prick sensation
  • Ankle reflexes
  • Vibration perception
  • Plantar light touch sensation

21

What is the Romberg test? What does an abnormal finding indicate? 

  • Position sense: stand with feet together and eyes open, then close both eyes for 30 seconds without support
  • Abnormal = inability to maintain upright posture, some minimal swaying is normal
    • May indicate sensory or cerebellar ataxia

22

What is reinforcement and how can it be used to assess reflexes? 

Reinforcement = used when reflexes seem diminished or absent - isometric contraction of other muscles for 10 seconds that may increase reflex activity

Eg. Have patient lock fingers and pull hands against each other when testing the patellar reflex

23

What are meningeal signs?

  • Nuchal rigidity = neck stiffness with resistance to flexion; found in patients with acute bacterial meningitis and subarachnoid hemorrhage
  • Brudzinski = flexion of the hips and knees in reaction to neck flexion
  • Kernig = pain and increased resistance to knee extension
  • joint accentuation of headache

24

What are causes of neurologic headaches and how would they present?  (3)

  • Subarachnoid hemorrhage: very severe thunderclap headache; associated with N/V, LOC, neck pain
  • Meningitis: steady, throbbing, severe; fever, stiff neck, photophobia, change in mental status
  • Mass lesions: aching, steady dull pain worse on awakening and better after several hours; associated with seizures, hemiparesis, field cuts, personality changes, N/V, vision change, gait change

25

What findings are consistent with Parkinson’s disease? 

Patients are slow getting started

Short, shuffling steps

Decreased arm swings

Turns around stiffly “all in one piece”

Stooped posture

Pill-rolling tremor

26

How would the FNP assess sensory function in the infant? What would abnormal findings indicate? 

 

Test for pain sensation by flicking palm or sole with your finger - observe for withdrawal, arousal and change in facial expression

Change in facial expression + cry but no withdrawal can indicate weakness or paralysis

27

Primitive reflexes: Palmar grasp 

Test, infant response, normal resolution, what does persistence indicate?

Test: place fingers into infants hand's and press against palmar surfaces

Infant response: infant should flex all fingers to grasp your fingers

Normal resolution: present until 3-4 months

Persistence beyond 4-6 months suggests pyramidal tract dysfunction

Persistence of clenched hand past 2 months suggests CNS damage

28

Primitive reflexes: Plantar grasp

Test, infant response, normal resolution, what does persistence indicate?

Test: touch sole at the base of the toes

Infant response: toes will curl

Normal resolution: present until 6-8 months

Presence past 8 months suggests pyramidal tract dysfunction

29

Primitive reflexes: Rooting reflex

Test, infant response, normal resolution, what does persistence indicate?

Test: stroke the perioral skin at the corners of the mouth

Infant response: mouth will open and infant will turn head toward the stimulated side and suck

Normal resolution: present until 3-4 months

Absence indicates severe generalized or CNS disease

Persistence beyond 4 months = neuro disease

30

Primitive reflexes: Moro reflex

Test, infant response, normal resolution, what does persistence indicate?

Test: hold supine and lower body abruptly 1 foot

Infant response: arms will abduct and extend, hands will open, legs will flex, may cry;

Normal resolution: present until 4 months

Persistence beyond 4 months suggests neuro disease, persistence beyond 6 months strongly indicates neuro disease