Neuro H&P- lec 2

A sudden onset w/ possible slow improvement suggests ________

vascular event

gradual onset and gradual progression suggests _______

tumors, dementia

exacerbations and remissions suggests _______

demyelinating disease, delirium

What are the “must not miss" symptoms?

• “worst HA of my life” / thunderclap HA (subarachnoid hemorrhage)

• sudden blindness

• back pain worse at night

• bowel/bladder incontinence

• suicidal ideation w/ plan

a problem with what lobe is responsible for disorientation and amnesia?

temporal

what are the LOC descriptions in order?

awake and alert, lethargic, obtunded, stuporous, comatose

What does lethargic mean?

falls asleep easily

what does obtunded mean?

confused, difficult to arouse

what does stuporous mean?

arouse w/ painful stimulation

what does comatose mean?

no response to painful stimulation

When evaluating the appearance of a patient, what might one sided grooming be indicative of?

cortex lesion

What are the parts of sensorium?

orientation

attention span

memory

fund of information

abstract thinking

constructional ability

What score on a Folstein Mini Mental Status Exam (MMSE) would suggest a cognitive disorder?

<24 out of 30

What does aphasia mean?

unable to produce speech / without speech (usually after brain damage)

what does dysphonia mean?

difficulty producing voice sounds

what does dysarthria mean?

difficulty articulating individual sounds

Which type of aphasia?

• receptive aphasia

• can form words w/o difficulty but errors in content

• unaware their responses are nonsense

• lesion in temporal/parietal lobe language area

wernicke’s

Which type of aphasia?

• expressive aphasia

• unable to form or find words; unable to produce words & sentences

• pt is aware of deficit

• lesion in anterior speech area

broca’s

Which motor exam score represents full strength against resistance?

5/5

Which motor exam score represents movement against some resistance?

4/5

Which motor exam score represents movement against gravity only?

3/5

Which motor exam score represents movement w/ gravity eliminated?

2/5

Which motor exam score represents muscle contraction palpable but no movement

1/5

Which motor exam score represents no contraction or movement?

0/5

Which tract is associated with pain and temperature?

lateral spinothalamic tracts

Which tract is associated with position and vibration?

posterior/dorsal columns

Which tract is associated with light touch and pressure?

anterior spinothalamic

Which DTR score reflects hyperactive +/- clonus?

4/4

Which DTR score reflects exaggerated response?

3/4

Which DTR score reflects normal response?

2/4

Which DTR score reflects diminished response?

1/4

Which DTR score reflects absent reflexes?

0/4

What are causes of hyperreflexia?

interruption of UMN pathways (MC);

also hypocalcemia or metabolic disorders

When the lesion is above the UMN decussation, hyperreflexia and weakness are ______

contralateral

When UMN lesions cause increased reflexes on one side, weakness would be _____

ipsilateral

Motor: Deltoid

Reflex: Biceps tendon

Sensation: upper outer arm

C5

Motor: wrist extension

Reflex: brachio-radialis tendon

Sensation: lateral forearm

C6

Motor: wrist flexion

Reflex: triceps tendon

Sensation: middle finger

C7

Motor: finger flexion

Reflex: none

Sensation: ring/pinky finger

C8

Motor: tibialis anterior (foot inversion)

Reflex: patellar tendon

Sensation: lower thigh and patella & dorsum of foot under arc

L4

Motor: extensor digitorum longus

Reflex: none

Sensation: outer or medial calf & great toe

L5

Motor: peroneus longus and brevis

Reflex: achilles tendon

Sensation: lateral foot/pinky toe

S1

what is tibialis anterior innervated by?

L4 via deep peroneal nerve

What is foot drop?

inability to dorsiflex foot caused by peroneal nerve injury

DTRs are _____

monosynaptic

Abdominal, cremasteric, anal wink, babinski, and clonus reflexes are ______

polysynaptic

What would decrease or abolish polysynaptic reflexes?

conditions that interrupt pathways b/t brain and spinal cord

What reflex?

• T8- T9 (upper) and T11-T12 (lower)

• normal response to skin stroke is twitching of the umbilicus towards the quadrant stimulated

• used when a thoracic spinal cord/UMN lesion is suspected

abdominal

What reflex?

• L1-L2

• elevation of ipsilateral testicle in response to stroking inner thigh

• used with suspected UMN lesions

cremasteric

What reflex?

• S2-S4

• pricking skin around anus causes quick twitch like constriction of anal sphincter

• used for suspected sacral or cauda equina lesions

anal wink

What reflex?

• great toe flexes with plantar stroke; extension implies UMN interruption

• dorsiflexion of big toe and fanning of other toes → positive sign → lesion on the corticospinal tract

babinski / plantar

What reflex?

• rhythmic oscillation of body part elicited by quick stretch and maintained by slight pressure

• usually tested at ankle w/ quick dorsiflexion of foot

• normal → one clonic jerk

• abnormal → sustained clonic jerks → interruption of pyramidal tract/UMNs; corticospinal dz

clonus

What reflex?

• indicator of UMN weakness → supination weaker than pronation in UE leading to pronation of affected arm

• pronation of one forearm → contralateral lesion in corticospinal tract

• sideward or upward drift → loss of position sense

• arm drops w/o pronation → they’re faking

pronator drift

what is the cerebellar function?

coordinate willful muscular contractions and maintain posture

How do you test cerebellar function?

finger to nose, heel to shin, rapid alternating movements, gait, romberg, nystagmus

what is dysdiadochokinesis?

inability to perform rapidly alternating movements; usually caused by MS in adults and cerebellar tumors in children

How would gait appear in a patient w/ a cerebellar lesion?

broad based stance and gait

When evaluating gait, what is a highly sensitive indicator of upper extremity weakness?

a slight decrease in arm swinging

What is the most sensitive way to test for foot dorsiflexion weakness?

walking on heels

what is the best way to test early foot plantar flexion weakness?

walking on toes

What can you assume about the nervous system of a comatose patient?

affected at brainstem level or above

What is the goal of a neuro exam in a comatose patient?

determine if induced by structural lesion or from a metabolic derangement or both

What are possible causes of comas?

Glucose (hyperosmolar or hypoglycemia)

Anoxia, acidosis, alcohol

Medications (MCC)

Electroytes, environment (hypothermia)

Tumor, toxins, trauma

Infections

Metabolic, adrenal, renal, hepatic

Epilepsy

Stroke, (p)sychiatric pseudocoma

What are ways to produce a noxious stimulus in a comatose patient?

• press very hard w/ thumb under bony superior roof of orbital cavity

• press pen hard on one of pt’s fingernails

• pinch skin on face, chest, or forearm

Which posturing has a better prognosis?

decorticate

What is decorticate posturing?

adduction of upper arms, flexion of lower arms, wrists and fingers; extended lower extremities

what is decerebrate posturing?

adduction of upper arms, extension and pronation of lower arms; extension of lower extremities

Which posture results from damage to upper brain stem?

decerebrate

which posture results from damage to one or both corticospinal tracts?

decorticate

What Glasgow Coma Score is seen in comatose patients?

8 or less (no oral medication)

what are the first signs of pure autonomic failure?

postural hypotension, impotence, disturbance of micturition