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Sasha: Module 11 Neurology > CA powerpoints > Flashcards

Flashcards in CA powerpoints Deck (138)
1

7 Major components of the Neurological exam 

•Mental Status

•Cranial Nerves (I-XII)

•Motor System

•Cerebellar Function

•Sensory System

•Deep Tendon Reflexes (DTRs)

•Special Tests, if indicated

2

•Is the mental status intact?

•Are your findings symmetric?

•Where is the lesion? If findings are asymmetric or abnormal, is the lesion in the central nervous system or in the peripheral nervous system?

 

what are these questions?

questions to really think about when seeing a pt

3

brain, brainstem, spinal cord

CNS

4

12 CNs and peripheral nerves (including spinal nerves – 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal)

PNS

5

Organization of Exam

  • Assess mental status
    • General appearance/presentation
    • Orientation x 4
  • Test cranial nerves
  • Assess motor system
    • Inspection
    • Muscle strength
  • Assess sensory system
    • Light touch, superficial pain, vibratory sense, proprioception
  • Check deep tendon reflexes (DTRs)
  • Test cerebellar function
    • Rapid alternating movements, point-to-point movements, gait
  • Special tests, if indicated (by PE or ROS)

6

Reflects the patient’s capacity for arousal or wakefulness; determined by level of activity that patient can be aroused to perform in response to stimuli from examiner

Level of Consciousness

7

–Do NOT dilate pupils

–Do NOT flex neck if there is any question of trauma to head or neck (x-ray first)

patient in stupor or coma…

8

using normal tone of voice, patient’s arousal intact; responds fully & appropriately

Alert

9

using loud tone of voice, patient appears drowsy but opens eyes and responds then falls asleep

Lethargic

10

shake patient gently; patient opens eyes but responds slowly, somewhat confused (ie drunk)

Obtunded

11

apply painful stimulus to arouse patient from sleep, verbal responses slow/absent, unresponsive when stimulus ceases

Stuporous

12

unarousable w/ eyes closed after repeated painful stimuli, no response to environment

 

...painful stimuli with no response....

Comatose

13

Explain the 3 main aspects of the glasgow coma scale and then the ratings under each main componenet

 

1. (4)

2. (6)

3. (5)

 

I know this is a long flashcard but this is important to known... i can see her explaining a pt and asking us to assess what their glasgow coma scale is. At least those are questions they would do in my EMT class who knows.....

•Eye opening

–None (1) Even to supraorbital pressure

–To pain (2) Pain from sternum/limb/supraorbital pressure

–To speech (3) Nonspecific response, not necessarily to command

–Spontaneous (4) Eyes open, not necessarily aware

•Motor response

–None (1) To any pain; limbs remain flaccid

–Extension (2) Shoulder adducted and shoulder and forearm internally rotated

–Flexor response (3) Withdrawal response or assumption of hemiplegic posture

–Withdrawal (4) Arm withdraws to pain, shoulder abducts

–Localizes pain (5) Arm attempts to remove supraorbital/chest pressure

–Obeys commands (6)  Follows simple commands

•Verbal response

–None (1) No verbalization of any type

–Incomprehensible (2) Moans/groans, no speech

–Inappropriate (3) Intelligible, no sustained sentences

–Confused (4) Converses but confused, disoriented

–Orientated (5) Converses and is oriented

14

hIghest grade you can get on glasgow coma scale

and lowest 

 

 

 

Lowest 3

Higherst 15

15

patients w/ scores of 3-8

usually are considered to be in a coma

16

no pupillary reaction to light

probably mid brain issue

17

•Midposition fixed pupils

•One large pupil

•Small or pinpoint pupils

•Large pupils

Pupils in Comatose Patients

18

When testing if meningeal inflammation first, make sure there is NO

injury to cervical vertebrae or spinal cord (if trauma, x-ray first)

19

with patient supine place hand behind the patient’s head flex neck forward, chin to chest (check for nuchal rigidity)

•Test if meningeal inflammation suspected  (eg, meningitis or subarachnoid hemorrhage)

20

•Positive if flexion of both hips & knees is noted when neck is flexed

Brudzinski’s Sign

21

•Positive if pain & increased resistance is noted to straightening the knee after hip & knee are flexed 

Kernig’s Sign

22

Fever, headache and altered level of concisouness

with menengitis

23

Test if mental function is impaired; may indicate

metabolic encephalopathy

24

•Ask patient to “stop traffic” by extending both arms w/ hands cocked up – watch for 1 to 2 minutes

•Positive if sudden, brief, nonrhythmic flexion of hands and fingers

Asterixis

25

CN I

smell

26

CN II

– visual acuity, visual fields, funduscopic exam

27

CN II, III

– pupillary reactions (direct and consensual)

28

CN III, IV, VI

extraocular movements (including convergence)

29

CN V

corneal reflexes, facial sensation (3 areas), clinch teeth

30

CN VII

facial movements (raise eyebrows, close eyes, smile, frown, show upper/lower teeth, puff out cheeks)

31

CN VIII

hearing (whispered voice)  (sensory/neuro or cognitive loss)

32

CN IX, X

swallow, say “ah,” gag reflex

33

CN V, VII, X, XII

voice and speech

34

CN XI

 shoulder and neck movements

35

CN XII

tongue symmetry and position

36

with excessive brain swelling you may see _____________ so look in daaa eye

papillary edema (swelling around disc)

37

Weber

is testing for?

if conductive loss?

If sensorineural hearing loss?

•Test for lateralization

•If conductive hearing loss, lateralizes to impaired ear

•If sensorineural hearing loss, lateralizes to good ear

38

 

impaired “air through ear” transmission

loss is conduction

39

from damage to cochlear branch of CN VIII

sensorineural 

40

Rinne

testing for what?

if sensorineural hearing loss?

if conductive hearing loss?

•Test for air and bone conduction

•If sensorineural hearing loss, AC>BC

•If conductive hearing loss, BC=AC or BC>AC

 

AC: air conduction

BC: Bone conduction

41

sinusitis, smoking, aging, cocaine use, Parkinson’s disease

CN I

42

papilloedema, glaucoma, stroke, retinal emboli, optic neuritis, pituitary tumor

CN II

43

*anisocoria (unequal pupils), intracranial hemorrhage, transtentorial herniation, Horner’s syndrome

 

*anisocoria can be a normal variant in a percentage of people

CN II, III

44

nystagmus (involuntary jerking movement of eyes), *ptosis (drooping of upper eyelids), diplopia, astigmatism, myasthenia gravis, Grave’s disease, Horner’s syndrome, cerebellar disease

CN III, IV, VI

45

stroke, CNS lesions, trigeminal neuralgia, acoustic neuroma

CN V

46

Stoke, Bell's Palsy

CN VII

47

cerumen impaction, otitis media, Meniere’s disease, aging

CN VIII

48

pharyngeal weakness, CN X lesion

CN IX, X

49

aphonia (loss of voice) due to vocal cord paralysis, dysarthria (poor articulation) due to cerebellar disease, aphasia (disorder in producing or understanding language) such as Wernicke’s aphasia or Broca’s aphasia

CN V, VII, X, XII

50

trapezius atrophy due to peripheral nerve disorder, bilateral weakness of sternomastoids

CN XI

51

cortical lesion, amyotrophic lateral sclerosis, polio

CN XII

52

–Body position

–Involuntary movements

–Characteristics of muscles (bulk, tone, & strength)

–Coordination (includes cerebellar function)

Things to focus on in motor system

53

3 types of tremors

1. resting

2. postural

3. intention

54

pill-rolling tremor of parkinsonism

resting tremor

55

, benign essential/familial tremor

Postural tremor

56

cerebellar disease, multiple sclerosis

Intention tremor

57

–Oral-facial dyskinesias (eg, tardive dyskinesia)

–Tics (eg, Tourette’s syndrome)

–Dystonia (eg, torticollis)

–Athetosis (eg, cerebral palsy)

--Chorea (eg, Huntington’s disease)

•Involuntary movements

58

increased tone; rate-dependent,  increasing w/ rapid movement(eg, stroke)

Spasticity

59

– increased resistance throughout ROM; it is not rate-dependent; “lead pipe rigidity.”

Rigidity

60

marked floppiness (eg, Guillain-Barre & spinal shock)

Flaccidity

61

sudden changes in tone w/ passive ROM (eg, dementia)

Paratonia

62

•0 =  No contraction noted

•1 = Barely detectable contraction

•2 =  Active movement with gravity eliminated

•3 =  Active movement against gravity

•4 =  Active movement against gravity & some resistance

•5 =  Active movement against full resistance w/o evident fatigue – This is NORMAL strength

Scale for Grading Muscle Strength

63

dermatones

64

Dermatomes of cervical spine

65

for C4-C5, its the ______ nerve thats affected but for T4-T5, it would be ______ affected because of that extra C8 nerve

that like for C4-C5, its the C5 nerve thats affected but for T4-T5, it would be T4 affected because of that extra C8 nerve

66

Deltoid and biceps (shoulder abduction and elbow flexion)

C5

67

Biceps flexion and wrist extensors

C6

68

Triceps, wrist flexors and finger extensors

C7

69

:Finger flexors and interossei muscles     

(aB and aD duction of the fingers)

C8

70

Interossei muscles ONLY

T1

71

head

C1-C2

72

Diaphragm, breathing

C3-C4

73

Go back to the ppt and look at the cool images from slide 28-32... the pictures are not copying over well to brain scape

fhdusiagvidsoabvisdba neuro hdiasbgjdsabvjdabvdja

74

Dermatomes of Lumbar Spine

75

Hip flexion

L2

76

Knee extension

L3

77

Ankle dorsiflexion

L4

78

Great toe extension

L5

79

AnkIe plantar flexion, ankle eversion, hip extension

S1

80

Knee flexion

S2

81

again look at the cool pictures about L roots from slide 35-37

or dont... doesnt really matter haha

82

If shoulder muscles seem weak or atrophic, look for

winging

83

•Ask patient to extend both arms and push against a wall

looking for winging of scapula

84

___________ if medial border of scapula juts backward, suggesting weakness of serratus anterior muscle, seen in muscular dystrophy or injury to long thoracic nerve

winging

85

If patient has low back pain w/ lumbosacral radiculopathy (sciatica if in S1 distribution), test

Straight-leg raise on each side

86

•Positive for lumbosacral radiculopathy if pain radiates into ipsilateral leg (foot dorsiflexion can further increase leg pain)

Straight-Leg Raise

87

3 types of  Cerebellar Function Tests

•Rapid alternating movements

–In cerebellar disease, dysdiadochokinesis is noted

•Point-to-point movements

•Gait

–In cerebellar disease, ataxia is noted

88

balance disorder

Cerebellar dysfunction

89

•Stand w/ feet together and eyes open, then close eyes for 30-60 seconds, only minimal sway should occur

Romberg Test

90

•Stand for 30 seconds w/ arms straight forward, palms up and eyes closed. Then, tap arms briskly downward at the same time

Test for Pronator Drift

91

Abnormalities in gait

Spastic Hemiparesis

Spastic gait

scissors gait

92

Abnormalities in gait

 

Parkinsonian Gain

Propulsive gait

Steppage gait

93

cerebellar ataxia

wide and unsteady gait

94

sensory ataxia

wide, unsteady AND heel strikes first

95

Sensory Sytsem

 

4 exam tests

•Light touch

•Pain (dull + sharp)

•Vibration

•Proprioception

96

•If touch and position sense are intact, you can proceed to testing the sensory cortex w/ __________________ 

discriminative sensations

97

–Stereognosis

–Graphesthesia

–Two-point discrimination

–Point localization

–Extinction

discriminative sensations  (testing of sensory cortext)

98

Ankle reflex

primary S1

99

Knee reflex

L2, L3, L4

100

Brachioradialis reflex

C5, C6

101

Biceps reflex

C5, C6

102

Triceps reflex

C6, C7

103

If DTRs (deep tendon reflexes) seem hyperactive (4+), test for _____

clonus

104

•Dorsiflex and plantar flex foot a few times then sharply dorsiflex foot and hold – look/feel for rhythmic oscillations between dorsiflexion and plantar flexion

testing for Clonus

105

•If clonus present, may indicate 

central nervous system disease

106

Cutaneous Stimulation Reflexes

 

•Briskly stroke each side of  abdomen above (T8, T9, T10) & below (T10, T11, T12) umbilicus w/ wooden end of cotton-tipped applicator

Abdominal Reflexes

107

if Abdominal Reflexes absent

may indicate central or peripheral nerve disorders

108

  • Stroke lateral aspect of sole from heel to ball of foot, curving medially across the ball – note movement of great toe
  • Positive if dorsiflexion of great toe

Babinski Response (L5, S1)

109

dorsiflexion of great toe in Babinski response may indicate:

–CNS lesion in corticospinal tract
–Unconscious states from drugs/alcohol intoxication
–Postictal period after seizure 

110

•Using dull object (eg, cotton swab), stroke outward in 4 quadrants from anus

Anal reflex

111

If loss of anal reflex contraction, may indicate

cauda equina lesions (S2-3-4)

112

so what are the 4 relfexes we jsut learned?

–assessing DTRs (like we have always done)

–Clonus

–Abdominal Reflexes

–Babinski Response

113

•Used to diagnose stroke, determine location and size of tumor, aneurysm, or vascular formation

•Dye injected via capsule placed via catheter

•Serial x-rays taken

•Negative side effects; warmth, slight discomfort

Cerebral Angiogram

114

 used to diagnose neuromuscular disorders (may also confirm carrier status for genetic disorders)

 

Muscle and/or nerve biopsies 

115

 are used to determine tumor type

•Brain biopsies

116

• the removal of small amount of spinal fluid via bedside sterile procedure

•**Common after affect is a headache – helped by having the patient lie flat

•Diagnostic of infections such as meningitis, helps in diagnosis of MS, measure of intracranial pressure

Lumbar Puncture - “Spinal Tap”

 

Cerebrospinal Fluid Analysis

117

3 contraindications for LP

•Increased Intracranial Pressure

•Coagulopathy

•Brain Abscess

118

•Age > 60

•Immunocompromised

•Known CNS Lesions

•Seizure in last week

•Altered Consciousness

•Focal findings on Neurological Exam

•Papilledema on Physical Exam

Perform a Brain CT Prior to LP….

119

Lab Studies Performed on Cerebrospinal Fluid

•Cell Count and differential

•Glucose and protein levels

•Gram stain, culture and sensitivity

 

•Viral titers, VDRL tests, Crytococcus Antigen, ACE levels, others

120

Position for LP

121

•Noninvasive, Painless

•Detect bone and vascular, certain brain tumors, cysts, herniated discs, spinal stenosis, encephalitis, blood accumulation, intracranial bleeding in stroke, tissue damage in trauma

•Drawbacks – some radiation (avoid in pregnancy), dye sensitivities when dye used, claustrophobic patients

CT Scan

122

•Small amount of dye injected via x-ray guidance into the spinal disc, CT then completed

•May cause some residual discomfort requiring short term pain medication

Discography

123

•Used to detect problems with spine and spinal nerve roots

•Lumbar Puncture – fluid is mixed with contrast dye and injected into spinal sac.

•Allows for clearer image of spinal canal and nerve roots

•Patient may have post procedure headache, residual pain

Cisternography – Intrathecal contrast-enhanced CT Scan

124

•Monitors brain activity through the skull

•Assists in diagnosis of seizure disorders, tumor, tissue damage post TBI, inflammation of the brain/spinal cord, psychiatric disorders, sleep disorders

•Pre procedure – patients should avoid caffeine and rx/non rx drugs that impact nervous system

Electroencephalography (EEG)

125

•Diagnoses nerve and muscle dysfunction and spinal cord disease

•Measures electrical activity from brain and/or spinal cord to a peripheral nerve root

•Usually completed in conjunction with a Nerve Conduction Velocity (NCV) test – which measures electrical energy by assessing the nerve’s ability to send a signal

Electromyography (EMG)

126

•A group of tests used to diagnose disorders such as involuntary eye movement, dizziness and balance disorders

•Involved electrode taped around eyes to record eye movements

•Infrared photography may also be used to evaluate eye movements

Electronystagmography (ENG)

127

•Measure the electrical signals to the brain generated by hearing, touch, and sight.

•Used to evaluate sensory nerve problems, confirm MS, brain tumor, acoustic neuroma, spinal cord injury

Evoked Potentials (also called Evoked Response)

128

•acoustic issues

 

Auditory evoked potentials

129

 detect loss of vision from optic nerve nerve damage

Visual evoked potentials

130

evaluate for nerve damage or degeneration from cord injury or deg. disease

Somatosensory EP

131

•Used extensively – assists in diagnosis of brain and spinal cord tumor, eye disease, inflammation, infections, vascular irregularities that can lead to stroke

•May also be used to monitor degenerative disease

•Used to quantify brain trauma

MRI

132

•Injection of a water or oil based contrast dye into the spinal cord to enhance x-ray imaging of the spine

•Used to diagnose spinal nerve injury, herniated discs, fractures, back or leg pain, and spinal tumors

•Again – patients may experience headache post lumbar puncture

Myelography

133

•Provides 2 and 3 dimensional pictures of brain activity by measuring radioactive isotopes that are injected into the bloodstream.

•Used to detect or highlight tumors, diseased tissue, measure cellular and/or tissue metabolism, monitor blood flow, determine brain injury post trauma, substance abuse

Positron Emission Tomography (PET Scan)

134

•Measures brain and body activity during sleep

•Used to detect sleep disorders, restless leg syndrome, insomnia, obstructive sleep apnea

•Painless, noninvasive, risk-free

Polysomnogram

135

•Evaluates blood flow to tissue

•Follow up test to MRI to diagnose tumors, infections, degenerative spinal disorders, stress fractures.

•Same theory as PET utilizing radioactive isotope, a rotating camera and production of a detailed 3 dimensional image of blood flow and activity in the brain

Single Photon Emission CT (SPECT)

136

•Analysis blood flow to the brain and can diagnose stroke, brain tumors, hydrocephalus and vascular problems

•Fetal Ultrasound to Determine Pathology prior to birth

Neurosonography (Ultrasound of Brain and Spinal Cord)

137

used to view arteries and blood vessels in neck, determine risk of stroke

Transcranial Doppler US

138

•Uses infrared sensing devices to measure small temperature changes between the two sides of the body or within a certain organ

•Used to detect vascular disease of head and neck, soft tissue injury, nerve root compression, some degenerative disorders

•Generates a 2 dimensional picture, is safe, risk-free

Thermography (Infrared Thermal Imaging)