MPA 531 Patient History and Physical Diagnosis - Nervous System

How do you assess for CN I?

- Olfactory Nerve

- Check for nasel patency

- Present patient with familiar odors while eyes are closed

What are normal vs. abnormal CN I responses?

Normal - Perceives odor on each side and identifies smell

Abnormal - Inability to perceive odor/identify smell which can occur in sinus conditions, head trauma, smoking, etc.

How do you assess for CN II?

- Optic Nerve

1) Test Visual Acuity

2) Ealuate Optic Fundi with ophthaloscope

3) Assess visual field by confrontation

4) Inspect size, shape and symmetry of pupils

5) Assess pupillary response

How to assess for CN III?

- Oculomotor Nerve

1) Pupillary responses (direct and consensual)

2) Near Response/Reflex

How to assess for CN III, IV and VI?

Oculomotor, Trocheal and Abducens Nerve

- Test by doing H pattern test to check extra ocular movements

How to assess for CN V?

Trigeminal Nerve

- Motor: Have pt clench teeth while palpating masseter and temporal muscles

- Sensory: Touch forehead, cheek and jaw for pain sensation and light touch

- Corneal Reflex - Have patient look up and away and lightly touch cornea with cotton wisp

What is a normal vs abnormal corneal reflex response?

Normal - Blinking

Abnormal - No blinking (seen in use of contacts and acoustic neuromas)

How to assess for CN VII?

Facial

Ask patient to raise eyebrows, frown, puff cheeks, smile, show teeth, close both eyes while trying to pen them

How to assess for CN VIII?

Use whispered voice or finger rub test

How to assess for CN IX and V?

- Assess for dysphagia

- Have pt say "ah" to see soft palate and pharynx

- Assess for gag reflex

How to assess for CN XI?

- Have patient shoulder shrug against resistance

- Have patient move face agains't your resistance

How to assess for CN XII?

Assess for articulation of patient's word and monitor tongue deviation

What is dysdiadochokinesia?

inability to perform rapid alternating movements

What techniques are used to properly assess coordination?

- Rapid Alternating Movements

- Point to Point Movements (finger-to-nose for UE and heel-to-shit for LE)

- Gait

- Posture while standing

What is the Romberg test?

Assesses patient's stance

- Pt should stand with their feet together, then close their eyes for 30-60 seconds to assess for any swaying or movement

What is the pronator drift?

Patient should stand for 20-30 seconds with both arms straight forward and palms up with eyes closed, and instruct patient to keep arms up and eyes shut as you tap arms briskly downward

What is dysmetria?

inability to control the distance, power, and speed of a muscular action

What is dysarthria?

Slurred speech due to muscle weakness

What is ataxia?

the loss of full control of bodily movements

What is the differences between upper motor neuron lesions and lower motor neuron lesions?

UMN Lesions - results in increased muscle tone, spasticity, paralysis/muscle weakness and exaggerated deep tendon reflexes

LMN Lesions - results in ipsilateral weakness, decreased muscles tone, muscle fasciculations, paralysis and decreased/absent reflexes

What types of symptoms are present in an upper motor neuron lesion that occurs in the spine?

Ipsilateral symptoms (SAME side as the injury)

What types of symptoms are present in an upper motor neuron lesion that occurs in the brainstem?

Contralateral symptoms (OPPOSITE side of the injury)

What is Parkinson's disease?

A disorder of the central nervous system that affects movement, often including tremors.

What is a 0 grade muscle strength?

No muscular contraction detected

What is grade 1 muscle strength?

a barely detectable flicker or trace of contraction

What is grade 2 muscle strength?

active movement with gravity eliminated

What is grade 3 muscle strength?

active movement against gravity

What is grade 4 muscle strength?

active movement against gravity and some resistance

What is grade 5 muscle strength?

Full range of movement against gravity & full resistance (normal muscle strength)

What is 4+ grade reflex?

Very brisk, hyperactive with clonus

What is a 3+ grade reflex?

Brisker than average but may not be indicative of a disease

What is a 2+ grade reflex?

average, normal

What is a 1+ grade reflex?

Somewhat diminished, low normal

What is a 0 grade reflex?

no response

What nerves are associated with the bicep reflex?

C5 & C6

What nerves are associated with the triceps reflex?

C6 & C7

What nerves are associated with the bracioradialis reflex?

C5 & C6

What nerves are associated with the patella reflex?

L2, L3, L4

What nerves are associated with the ankle reflex?

S1-2

What is a stroke?

Damage to the brain from interruption of its blood supply.

What is the leading risk factor for strokes?

Hypertension

What is Metabolic encephalopathy?

Metabolic encephalopathy refers to a spectrum of brain disorders caused by systemic metabolic disturbances.

(Organ failure, electrolyte imbalances, toxins, infections, or nutritional deficiencies.)

What is hepatic encephalopathy?

The loss of brain function when a damaged liver doesn't remove toxins from the blood.

Where should UE strength be assessed?

- Flexion (Biceps - C5 and C6)

- Extension (Triceps - C6-C8)

- Extension of wrist (C6-C8 and radial nerve)

- Grip Strength (C7, C8, T1)

- Finger abduction (C8, T1, ulnar nerve)

- Thumb Opposition (C8, T1, median nerve)

Where should LE strength be assessed?

Hips

Knees

Legs

Feet

What nerve(s) and muscle(s) are associated with flexion of the hip?

L2, L3, L4 - iliopsoas

What nerve(s) and muscle(s) are associated with adduction of the hip?

L2, L3, L4 - hip adductors

What nerve(s) and muscle(s) are associated with abduction of the hip?

L4, L5, S1 - gluteus medius and minimus

What nerve(s) and muscle(s) are associated with extension of the hip?

S1 - gluteus Maximus

What nerve(s) and muscle(s) are associated with knee extension?

L2, L3, L4 - quads

What nerve(s) and muscle(s) are associated with knee flexion?

L4, L5, S1, S2 - hamstrings

What nerve(s) and muscle(s) are associated with dorsiflexion?

L4, L5 - tibilalis anterior

What nerve(s) and muscle(s) are associated with plantar flexion?

S1 - gastrocnemius and soleus

What are the 4 discriminative tests used during a neuro exam?

1) Graphesthesia - Draw a number in pt's hand

2) Two-point discrimination - use paper clip to assess when pt feels two points vs one point

3) Point Localization - Touch a point on patient's skin and have pt identify where you touched

4) Extinction - Touch two areas on pt's body at the same time and ask pt where they feel the touch

What are the special tests that can indicate meningitis or subarachnoid hemorrhage?

- Nuchal rigidity

- Brudzinki's sign

- Kernig's Sign

How do you test for nuchal rigidity?

- Place pt supine

- Have pt bend neck forward to assess for pain

How do you perform Brudzinski's sign?

While flexing the pt's neck, observe hips and knees; hip and knee flexion observed in these pts is a positive test

What special tests can help us identify metabolic/hepatic encephalopathy?

Asterixis

How is the majority of strokes caused?

Ischemia

The most common cause of brain ischemia is the occlusion of the ________________________?

Middle Cerebral Artery

Clinical presentation in left sided stroke?

Aphasia

Clinical presentation in right sided stroke?

Hemineglect

Low frequency unilateral resting tremor is typical of _______________

Parkinson's

What is ABCD2 scoring system?

Helps us predict the likelihood of a stroke occurring after a TIA

TIAs are a major risk factor for ___________________?

Subsequent stroke

What are the three D's?

Delirum

Dementia

Depression

What is the screening performed for Delirum?

Confusional Assessment Method (CAM)

What is the screening performed for Dementia?

Mini-Mental Status Exam (MOCA)

What is the screening performed for Depression?

PHQ-2 followed by PHQ-9

What causes a stocking glove pattern of sensory loss?

Diabetic Peripheral Neuropathy

How is Kernig's sign performed?

Flex the patient's leg at the hip and knee, then straighten the knee.

Positive test is pain and increased resistance to extending the knee

What is past pointing?

If finger has repetitive and constant deviation to one side

What is dysmetria?

If the finger overshoots its mark but eventually reaching target during point-to-point movement

What is dsydiadochokinesia?

Slow, irregular, clumsy arm movements during rapid alternating movements

What are red flag symptoms of headache?

- Pt states "worst headache of my life" or "thunderclap headache"

- Sudden onset

- Onset after age 50

- Presence of fever or stiff neck

- AMS, seizures, papilledema or focal neurological findings

What are dermatomes?

Specific areas of the skin that receive sensory input from a single nerve root

What is the spinothalamic tract responsible for?

pain, temperature, crude touch

What is the posterior columnn responsible for?

vibration, proprioception, kinesthesia, pressure, fine touch

Lesions above decussation affect which side of the body?

The contralateral side

Lesions below decussation affect which side of the body?

The ipsilateral side

What is the corticospinal tract?

A descending somatic motor tract that is responsible for voluntary skeletal movement and cross the other side of the body

Are UMN's part of the CNS or PNS?

CNS

Are LMN's part of the CNS or PNS?

PNS

What is the extrapyamidal system?

A motor pathway that modulates automatic and involunatry movements

What is decussation?

crossing over

What CN's also carry parasympathetic innervation?

- Oculomotor

- Facial

- Glossopharygeal

- Vagus

Where does the spinal cord end?

L1-L2

What are the 3 parts of the brainstem?

midbrain, pons, medulla oblongata

What is the function of the cerebellum?

Balance and coordination

What are the four major regions of the brain?

cerebrum, diencephalon, brainstem, cerebellum

Brain tissue is composed of ________ & _________?

Gray Matter and White Matter

What does gray matter contain?

Neurons

What does what matter contain?

Myelinated (high fat content) axons

What are oligodendrocytes?

A type of glial cell responsible for myelination in the CNS

What are Schwann Cells?

A type of glial cell responsible for myelination in the PNS