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92 Cards in this Set

  • Front
  • Back
Neuro exam assesses what 9 divisions of neuroaxis?
higher cortical functioning
cranial nerves
cerebellum
motor system
sensory system
deep tendon reflexes
pathologic reflexes
Broca's aphasia?
Left frontal lobe. Inferior Frontal gyrus
Maintain comprehension
No fluency
Gertsmann's syndrome?
Left parietal lobe lesion

Left/right indiscrimination
finger agnosia
acalculia
agraphia without alexia anosognosia
What cortical function is found in the right temporal region?
hearing sounds, rhythm, music
Wernicke's aphasia?
Left parietal temporal defect
Superior temporal lobe
What are functions of the temporal lobes (Bilaterally) ?
learning and memory
olfaction: limbic
auditory cortex: heschel's gyrus
The perception of seeing objects bigger or smaller than they are is what?
Micropsia and macropsia

Right occipital lobe defect
propasagnosia
visual hallucinations
cortical blindness
Anton's syndrome (lack of awareness of being blind)
bilateral occipital lobe defect
What are the 5 muscles of CN III
Oculumotor
m: levator palpebrae look for ptosis
m: superior rectus look up and out
m: medial rectus adduction
m: inferior rectus look down and out
m: inferior oblique look up and in
What is Adie's tonic pupil?
On exam, the eye is dilated and doesn’t constrict to light (we’re blocking the parasympathetic pathway from the Edinger-Westphal nucleus). The pupil will constrict with near vision- but very slowly. That’s why we call it a “tonic pupil,” it’s tonically slow.
What is Argyl Robertson's?
bilateral small pupils that constrict when the patient focuses on a near object (they “accommodate”), but do not constrict when exposed to bright light (they do not “react” to light).
The eyes are “down and out” with a droopy eyelid
CN III lesion
Patient tilts their head away from the lesion
CN 4 lesion

Think trauma or cogenital head-tilt decompensated with age
The patient looks “cross-eyed.”
CN6

Consider intracranial pressure
Pie in the sky
lesion in the temporal

(lower problem, has upper deficiency)
Trochelar nerve: muscle and action?
Superior Oblique

Looks down and In
Corneal reflex test
5 in
7 out
Gag reflex test
CN9
CN10
An arm/leg that moves easier, or with less resistance, is the hypotonic limb

What problem in the brain is this?
Ipsalateral Cereberallar Hemispheric Lesion (as opposed to vermis lesion)
"HANDS- tremor"
Nmemonic for cerebellar function examination

H: hypotonia
A: ataxia or asynergy
N: nystagmus
D: dysmetria and dysdiadochokinesis
S: stance or gait
Tremor
What is ataxia?
Inability to coordinate voluntary muscular activity
(Cerebellar problem)
what are the types of nystagmus(s) seen in Cerebellar problems?
Optokinetic
gaze-evoked
downbeat
smooth pursuit
Dysmetria
refers to the in ability to precisely coordinate the force and timing of muscular contraction when moving a limb. When the limb falls short of its target, it is called hypometria. When the limb extends beyond its target, it is called hypermetria.
Dysdiadochokinesis
refers to the impaired ability to rapidly perform alternating movements, such as rapid alternating hand movements.
What is excessive rebound (Stewart Holmes sign)?
inability of muscles to correct changes in resistance

Cerebellar function problem
What kind of gait seen in a cerebellar lesion?
Wide based, unsteady , tendency to fall toward the unilateral hemispheric lesion (Same side)
"Ataxic"

Heel to toe is also difficult*
When is the pull test performed?
Parkinson's patients
A positional tremor is usually due to which disorder?
Metabolic disorders
(test with arms outstreched in the air)
Pill rolling tremor is a defect in what structure(s)?
Basal ganglia
Romberg sign is a test for what?
Sensory system
(eyes closed) - relies on semicircular canals

(eyes open) - eyes open and SC canals

Checking for lesion in dorsal columns (proprioception) or a peripheral neuropathy
A dermatome loss of sensation implicates what _____?
Radiculopathy - herniated intervertebral disk one which has become displaced from its normal position
Loss of sensation to the leg (But spares face and arms) implicates what type of lesion?
Vascular territory of the homunculus

Anterior cerebral artery

(If it were complete side, we think subcortical where all the fibers coalesce
Abnormal sensation only to the face indicates what?
Problem with the trigeminal nerve
A deep tendon reflex is a monosynaptic reflex that contains:
a. a sensory peripheral nerve that carries the impulse toward the spinal cord,
b. an afferent limb that allows the impulse to enter the spinal cord through the dorsal
roots,
c. an efferent limb that allows the impulse to exit the spinal cord through the ventral roots,
d. and a peripheral nerve that carries the impulse to a muscle for contraction.
What is a 4/4 reflex?
4/4: the reflex is elicited exceptionally easy, produces spread, and also produces clonus.
A lesion of the corticospinal tract shows what abnormal reflex?
Babinski Sign (primitive reflex that dissipates when brain myelinates)
What test do we perform to test for meningeal irritation?
Kernig sign

to evaluate patients with suspected meningeal irritation (i.e. meningitis). One places a patient supine on a bed, passively flexing the hip. The subsequent extension of a knee should normally not produce neck/back pain. If meningeal irritation is present, then passive extension of the knee produces the abnormal response of resistance of knee flexion. Click here to jump to the chapter on Kernig's sign.
What is a 4/4 reflex?
4/4: the reflex is elicited exceptionally easy, produces spread, and also produces clonus.
A lesion of the corticospinal tract shows what abnormal reflex?
Babinski Sign (primitive reflex that dissipates when brain myelinates)
What test do we perform to test for meningeal irritation?
Kernig sign and Brudzinski sign
Fatiguable weakness implies a lesion at the _____
neuromuscular junction
Contrast muscular dystrophy versus infammatory myopathy
Dystrophy= defect in the internal structure
Typically Dystrophin gene

Inflammatory = immune-mediate attack
What are findings in duchenne muscular dystrophy?
Extremely high creatine kinase (up to 150,000)

Doughy gastrocnemius - pseudo hypertrophy

Lordosis: weaknes of hip extensors

Trendellenburg sign: pevlic girl weakness: pelvic girldle tilt each time a leg is raised to take a step

Gower's sign: proxima lmuscle weakness. Rising from floor, goes to knees and elbows, extends knees and arms, "marches up himself" with hands and legs
What is happening?
classic dystrophic changes with marked variation in fiber size and endomysial fibrosis. A few fibers are undergoing phagocytosis.
How does Becker differ from Duchenne?
Occurs later in life (Duchenne is by age 13), less severe
CK levels don't reach as high (10,000 range)

**Look at histology to distinguish
What two sign's are present in Duchenne and Becker's?
Gower's and Trendellenburg's sign

Indicate pelvic girdle weakness
*Proximal weakness in both!!
Which dystrophy produces a pattern of weaknes in face, scapulae, arm?
Fascioscapulohumeral Muscular Dystrophy

CK's can be normal, or elevate minimally up to 5x normal

*Foot drop, pectoralis atrophy, scapular winging
This dystrophy is caused by a genetic trinucleotide repeat.

hatchet like face, with baldness, cataracts, cardiac conduction defects and presence of myotonia
Myotonic dystrophy
What are the 2 inflammatory myopathies? Presentation?
*Polymyositis
Associated w/interstitial lung disease
Perform muscle biopsy

*Dermatomyositis
(involves rash preceding weakness)
Associated with Ovarian Cancer
Tx: Prednisone
"Fatiguable weaknesses" - we suspect what disorder?
Neuromuscular junction disorder

Ptosis
Dysconjugate gaze
Dysphagia
Dysphonia - inpairment in ability to produce voice sounds
Proximal muscle arm and leg weakness
what 3 diagnoses can be made when you localize a lesion to the neuromuscular junction?
Myasthenia Gravis

Lambert Eaton Myasthenic syndrome

Botulism
Main difference between Myasthenia Gravis and Lambert Eaton Myasthenic gravis
Myasthenia: Immune mediated Destruction of post-synaptic

associated with thymoma

LEMS: immune-mediated
destruction of pre-synaptic

associated with small cell lung cancer
What is this chart interpreting?
EMG test of muscles

Top is normal

Middle is Myasthenia (repetitive simulation shows decrement)

Bottom is LEMS (increment in the complex motor action potential)
What is peripheral neuropathy?
refers to damage to the longest nerves that convey either sensation, strength, autonomic function, or any combination thereof
Sensory neuropathies usually start where and migrate to?
Start distally and progress proximally.

Can manifest numbness, tingling or dampened sensation
Which symptoms tend to follow sensory symptoms?
Motor symptoms

i.e. weakness in great toe, inability to dorsiflex, producing footdrop...catching toes on uneven surfaces
What other autonomic symptoms may occur alongside peripheral neuropathy?
dys-accommodation of the lens of the eyes
cardiac arrhythmias
dys-hydrosis, anhydrosis, or hyper-hydrosis
gastroparesis
constipation
erectile dysfunction, or loss of nocturnal penile tumescence
edema or erythema of digits
Most peripheral neuropathy are idiopathic...
The others can be explained by what problems?
diabetes or impaired glucose tolerance
hypovitaminosis B12
vasculitis
syphilis
monoclonal gammopathy
thyroid dysfunction
When interrogating for possible causes of clinical neuropathy: what tests can you perform?
2-hour oral glucose tolerance test
vitamin B12
W-ESR
RPR
serum protein electrophoresis with immunofixation
free T4 and TSH
Most common dermatomes to know?
C5: shoulder
C6 thumb and index finger
C7 middle finger
C8 ring and pinkey finger
T4 nipple line
T10 umbilicus
L2 inguinal canal
What are the common myotomes to know (lower body)
L2- Leg adduction
L3- Hip flexion
L4- Knee extension
L5-Ankle dorsiflexion
S1-Plantar flexion
Testing deep tendon reflexes

Which 5?
C5 biceps brachii
C5/6 brachioradialis
C7 triceps
L4 patellar
S1 Achilles
what types of lesions produce lower motor neuron findings? (4)

Presentations? (5)
muscle, Neuromuscular junction,
Peripheral nerve, spinal nerve root/radical

atrophy of muscle
weakness of muscle
fasiculations
hypo or areflexia
hypotonia
Upper motor neuron lesion findings
Hypertonia
hyper-reflexia
Clonus
Babinski sign
Spasticity (Rate dependent)

*Clasped knife

lesions in spinal cord, brainstem, subcortex, cortex can cause UMN if corticospinal tract is lesioned

Findings are below the lesion
Causes of Spinal Cord Lesion
5 acute ; 2 subacute ; 3 chronic
Acute onset of signs and symptoms:

spinal cord infarct
acutely herniated disc
compression fracture producing impingement on the cord
epidural abscess
epidural hematoma

Subacute onset of signs and symptoms

multiple sclerosis plaques
syrinx (expanding cyst)

Chronic onset of signs and symptoms

spinal cord tumor
vitamin B12 deficiency (cobalamin)
syphilis
Which cranial nerves associated with parts of braintstem
12, 11, 10, 9 exit from the medulla
8, 7, 6, 5 exit from the pons
4, 3 exit from the midbrain
2, 1 exit from this level
Brainstem lesions lead to what findings? (Answers for each CN lesion)
1 decreased smell
2 decreased vision
3 double vision
4 double vision
5 decreased sensation
6 double vision
7 decreased strength of facial expression
8 deaf and dizziness
9 dysphagia and dysphonia
10 dysphagia and dysphonia
11 decreased head turning and shoulder shrug
12 dysarthria
How do you determine if a patient with Bell's palsy has a central problem (i.e. stroke) or a peripheral CN 7 lesion?
Lower CN7 lesions also produce:
1. metal dysgeusia, as CN7 carries taste from the tongue (water tastes metallic)
2. ipsilateral hyperacusis, as CN7 innervates the stapedius, which normally dampens loud
sounds
3. forehead weakness
Lesions in the brainstem are usually caused by what?
Hemorrhagic or ischemic stroke
Also tumors

MS is also possible (formation of plaques)
What are signs and symptoms of spinal cord lesions?
bilateral lower extremity weakness
bilateral lower extremity sensory dysesthesias (possible upper extremity involvement if cervical spine involved), with a sensory level
bowel and bladder retention or incontinence

**See normal findings above the lesion
**See UMN findings below the lesion
Brainstem and cerebellum receive circulation from?
Vertebral Arteries and the basilar artery and its subsequent arteries
what are symptoms that would suspect posterior circulation defect?
loss of consciousness
syncope
dizziness/vertigo
dysphagia
dysphonia
dysarthria
hemiparesis of face/arm/ leg equally invoved
hemidysethesias of face/arm/leg equally involved
Dysesthesia (Tingling) always implicates what type of lesion?
Subcortical lesion
Cortex signs and symptoms related to vascular causes:

What feeds arm/face and leg?
Face and arm > leg = MCA (middle cerebral artery)
Leg > face and arm = ACA (anterior cerebral artery)
What are 5 common causes of lesions showing cortical dysfunction?

4 common manifestations?
subdural or epidural hematoma
subdural or epidural abscess
meningioma
subarachnoid hemorrhage
seizures

Manifestations: Apraxia, aphasia (Broca /wernicke), agnosia, neglect
What is multiple sclerosis?
T-cell mediated disease that demyelinates only the CNS
**See plaques

Upper motor neuron findings
Spasticity
Hyper-reflexia/clonus
Babinski reflex
Increased tone (hypertonia)
What is seen here?
Multiple Sclerosis plaques

Present in 20's, 30's, 40's
with waxing and waning motor symptoms

**2 main eye findings: optic neuritis (may cause scotoma) and Internuclear Opthalmoplegia ( impairs adduction)
Typically bilateral?
What is optic neuritis?

What is affected?
Inflammation of optic nerve. Typically product of immune-mediated demyelination.

Prevents nerve from entering the brain (Affects afferent pupillary reflex)
What test do you perform when suspecting optic neuritis?
Swinging torch test

Should see constriction in both eyes if light shown in unaffected eye.

In the affected eye, eyes would dilate.

**Efferent pathway not effected in optic neuritis
What causes Korsakoff's syndrome?
Lack of Vitamin B1, Thiamine
(Alcoholics) **Damage to medial thalamus


anterograde amnesia
retrograde amnesia, severe memory loss
confabulation, that is, invented memories which are then taken as true due to gaps in memory sometimes associated with blackouts
meager content in conversation
lack of insight
apathy - the patients lose interest in things quickly and generally appear indifferent to change.
What two eye disorders do we associate with Multiple Sclerosis?
Optic Neuritis
and
INO (MLF lesion)
A right MLF lesion causes which inability?
Right eye is unable to look past midline (Adduct)
what are the 3 classifications of headaches?
Migraine - pulsatile and localize behind the eye. Commonly produce nausea and vomiting

Cluster - usually in men. Wake ppl up from sleep. Have histaminic symptoms: rhinorrhea, congestion, lacrima

Tension - worsen at the end of the afternoon/evening, are described as nonpulsatile, and produce neck stiffness. They have no aura or lateralizing features, and do not typically produce nausea or emesis.
what is decorticate posturing?
Implicates lesion above the red nucleus (midbrain) - removal of corticospinal pathways


produces flexed elbows with cluched fists in internal rotation, and leg extension with plantarflexion (tiptoe posturing). Think of it as the patient trying to touch the cortex of their brain.
What is decerebrate posturing?
lesions below red nucleus but above vestibular nucleus

produces opisthotonos (head and trunk extended), teeth clenched, and an extended elbow with cluched fists in external rotation, and leg extension and internal rotation with plantarflexion
What is seen in 3rd nerve lesion?

(3)
An eye that deviates down and out
Ptosis
Blown pupil
What are third nerve lesion causes (2)which may spare pupils?
DIabetes
Myasthenia Gravis
2 causes of third nerve lesions which also involve pupils
Aneurysm of posterior communicating artery

Tumor
Symptoms of parkinson's disease
Bradykinesia (slowness of movement)
Postural instability
Resting tremor
Cogwheel rigidity
Why can we not administer dopamine to parkinson patient's?
It can't cross the BBB!
So we give L-Dopa, a precursor of dopamine.
what are dopamine agonist drugs for parkinson patient's?
Pramipexole (mirapex)
Ropinerole (Requip)
What are the 3 categories (overall 6 kinds) of PNS autoimmune disorders?
PN:
Guillain Barre Syndrome (GBS)
Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)

NMJ:
Myasthenia Gravis (MG)
Lambert Eaton Myasthenic Syndrome (LEMS)

Muscle:
Polymyositis
Dermatomyositis