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108 Cards in this Set
- Front
- Back
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4 regions of the brain
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4 regions: cerebrum, diencephalon, brainstem and cerebellum
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each hemisphere is subdivided into:
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each hemisphere is subdivied into frontal, parietal, temporal and occipital lobes
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aggregations of neuronal cell bodies, rims surface of cerebral hemispheres, forming
cerebral cortex |
gray matter
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neuronal axons that are coated with myelin, myelin sheaths create the white color
allow nerve impulses to travel more rapidly |
white matter
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basal ganglia affect _____________
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basal ganglia: affect movement
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process sensory impulses and relays them to cerebral cortex
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thalamus: process sensory impulses and relays them to cerebral cortex
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hypothalamus
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• hypothalamus: maintains homeostasis and regulates temp, HR and BP
• affect endocrine system and goversn emotional behaviour • hormones secreted act directly on pituitary gland |
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_______________: connects upper part of the brain with the spinal cord
• 3 sections: _______________,__________,_____________ |
brainstem: connects upper part of the brain with the spinal cord
• 3 sections: midbrain, pons, medulla |
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consciousness depends on interaction between_____________________ and ____________________
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consciousness depends on interaction between intact cerebral hemispheres and reticular
activating (arousal) system |
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cerebellum
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• cerebellum: lies at base of brain, coordinates all movement and helps maintain body upright
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The spinal cord
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provides a serious of segmental relays with periphery, serving as a conduit for information flow
to and from brain |
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Spinal cord is divided into ____ segments. What are each of them?
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cervical (C1-C8),
throacis (T1-T12) lumbar (L1-L5) sacral (S1-S5) and coccygeal |
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most lumbar punctures are performed at ____________________.
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most lumbar punctures are performed at L3-4 or L4-5
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The Peripheral Nerves
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The Peripheral Nerves
• contain both sensory (afferent) and motor (efferent) • spinal and peripheral nerves carry impulses to and from the cord |
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T/F: spinal cord contains both gray matter and white matter
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true
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Motor Pathways
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• extending from upper motor neuron (UMN) through long white matter tracts, to synapes with
lower motor neurons (LMN) and into the periphery through peripheral nervous structures |
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UMN
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UMN (nerve cell bodies) lie in the motor strip of the cerebral cortex
• axons synapes with motor nuclei in the brainstem (for CN) and in spincal cord (for PN) |
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LMN
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LMN (anterior horn cells) have cell bodies in the spinal cord
• axons trhasmit impulses through anterior roots and spinal nerves into PN, terminating at the neuromuscular junction |
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This motor pathway mediates voluntary movement and integrates skilled, complicated or delicate movements by stimulating selected muscular actions and inhibiting others
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corticospinal (pyramidal) tract: mediate voluntary movement and integrate skilled,
complicated or delicate movements by stimulating selected muscular actions and inhibiting others |
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corticospinal (pyramidal) tract
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carry impulses that inhibit muslce tone
originate in motor cortex of brain motor fibers travel down into lower medulla, where they form an anatomical structure resembling a pyramid; fibers cross to opposite side of medulla and synapse with aneterior horn cells or with intermediate neurons |
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motor pathways between cerebral cortex, basal ganglia, brainstem, and spinal cord
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• basal ganglia system: motor pathways between cerebral cortex, basal ganglia, brainstem,
and spinal cord |
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basal ganglia motor pathway
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• helps maintain muscle tone and to control body movements, esp gross automatic
movements such as walking |
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recieves both sensory and motor input and coordinates motor activity,
maintains equilibirum and helps to control posture |
cerebellar system: recieves both sensory and motor input and coordinates motor activity,
maintains equilibirum and helps to control posture |
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when UMN systems are damaged above crossover of its tracts in the medulla, motor impairment develops on ___________________________
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opposite or contralateral side
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when UMN (nerve cell bodies) systems are damaged below crossover, motor impairment occurs on ____________
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same or ipsilateral side of body
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corticospinal tract is damaged or destoryed, its functions are reduced or lost ___________________
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below level of injury
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damage to LMN causes:
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damage to LMN causes ipsilateral weakness and paralysis, muscle tone and reflexes are
decreased or absent |
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• in UMN lesions, muscle tone is___________ and deep tendon reflexes are______________.
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• in UMN lesions, muscle tone is increased and deep tendon reflexes are exaggerated
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damage to basal ganglia system
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produces changes in muscle tone (often increase),
distrubances in posture and gain, slowness or lack of sponteous and automatic movement termed bradykinesia |
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cerebellar damage impairs...
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• cerebellar damage impairs coordination, gait, equilibirum and decreased muscle tone
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once inside cord, sensory impulses reach sensory cortex of brain via one of the two pathways:
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spinothalamic tracts or posterior columns
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at thalamic level,_______________ is perceived but,
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at thalamic level, general quality of sensation is perceived but fine distinctions are not made
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•A reflex is an_____________ ________________ response that may involve..
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relfex is an involuntary stereotypical response that may involve as few as two neurons, one
afferent (sensory) and one efferent (motor) across a single synapse |
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• each deep tendon reflex involves ___________________________.. which can help you...
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• each deep tendon reflex involves specific spinal segments, together with their sensory and
motor fibers, an abnormal reflex can help you to locate a pathologic lesion |
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ankle reflex spinal segment(s)
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ankle reflex: sacral 1 primarliy
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knee reflex spinal segment(s)
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knee reflex: lumbar 2, 3, 4
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supinator (brachioradialis) reflex spinal segment(s)
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• supinator (brachioradialis) reflex: cervical 5, 6
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biceps reflex spinal segment(s)
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• biceps reflex: cervical 5, 6
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triceps reflex spinal segment(s)
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triceps reflex: cervical 6, 7
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Finding in inner ear conditions, brainstem tumor
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vertigo in inner ear conditions, brainstem tumor
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bilateral proximal weakness in __________
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bilateral proximal weakness in myopathy
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bilateral, predominately distal weakness in ____________
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bilateral, predominately distal weakness in polyneuropathy
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arm or leg “go to sleep” following compression of a nerve, tingling, prickling,
or feelings of warmth, coldness or pressure |
parathesias:
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distorted sensations in response to a stimulus and may last longer than the
stimulus itself |
• dysesthesias:
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sudden but temporary loss of consciousness and postural tone that occur with
decreased blood flow to brain |
syncopy
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syncopy in young
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young people with emotional stress and warning symptoms of flushing, warmth or nausea
my have vasodepressor (or vasovagal) syncope of slow onset, slow offset |
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paroxysmal disorder caused by sudden excessive electrical discharge in cerebral cortex
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seizure
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_______________ is suddent neurologic deficit cause by cerebrovascular ischemia or hemorrhage
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stroke
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TIA lasting less than ____ hours, without underlying structural defects, most will progress to
___________. |
TIA lasting less than 24 hours, without underlying structural defects, most will progress to
stroke after TIA |
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most common cause of ischemic symptoms and signs is________________, which causes:
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most common cause of ischemic symptoms and signs is occlusion of middle cerebral
artery, which causes visual fields cuts and contralateral hemiparesis and sensory deficits |
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L hemisphere occlusion (stroke) produces what symptoms?
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in L hemisphere occulsion produces aphasia
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R hemisphere occlusion (stroke) produces what symptoms?
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R hemisphere neglect or inattention to
opposite side of body |
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stroke warning signs
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• sudden numbness or weakness of face, arm or leg
• sudden confusion, trouble speaking, or understanding • sudden trouble walking, dizziness, or loss of balance or coordination • sudden trouble seeing in one or both eyes •sudden severe headache |
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CN1
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• I - olfactory
• test sense of smell by presenting pt with familiar and nonirritating odors |
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CN2
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• II - optic
visual acuity • inspect optic fundi • disc pallor in optic atrophy, disc bulging in papilledema • test visual fields by confrontation • prechiasmal or anterior defects in glaucoma, retinal emboli, optic neuritis • bilateral hemianopsias from defects at optic chiasm from pituitary tumor • homonyouse hemianopsias or quadrantanopsia in postchiasmal lesions, u |
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CN2 and 3
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II and II - optic and oculomotor
• size and shape of pupil • anisocoria or difference of >0.4 mm in diamter of one pupil compared to other is normal • test pupillary reactions to light • minimal constriction in the large pupil if abnormality of pupillary constrictor muscle from iris disorder or CN III palsy with parasympathetic denervation, ptosis • test near response: which test pupillary constrcition, convergence and accomodation of lens • pupils constrict to light in Horner’s syndrome but due to sympathetic degeneration, affected pupil remains small (miosis) due to abnormal pupillary dilator muscle |
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CN III, IV, and VI
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• III, IV and VI - oculomotor, trochlear, abducens
• test EOM - look for loss of conjugate movements which cause diplopia Nervous System• monocular diplopia in local problems with glassess or contact lenses, cataracts, astigmatism, ptosis • binocular diplopia in CN III, IV, VI neuropahty, eye muscle disease from myasthenia gravis, trauma, thyroid opthalmopathy, internuclear opthalmophlegia • check convergence of eyes, identify any nystagmus • nyastagmus in cerebellar disease, esp with gait ataxia and dysarthria (increases in retinal fixation) and vestibular disorders (decreases with retinal fixation); also in internuclear opthalmoplegia • look for ptosis (drooping of upper eyelids) • ptosis in 3rd nerve palsy (CN III), Horner’s syndrome (ptosis, meiosis, anhidrosis), myastenia gravi |
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CN V
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V - trigeminal
• ask pt to clench his or her teeth, note strength of muscle contraction • ask pt to move jaw side to side • difficulty clenching the jaw or moving it to opposite side in masseter and lateral pterygoid weakness • unilateral weakness in CN V pontine lesions • bilateral weakness in cerebral hemispheric disease because of bilateral cortical innervation • CNS patterns from stroke include facial and body sensory loss on same side but from contralateral cortical or thalmic lesion • ipsilateral face but contralateral body sensory loss in brainstem lesions • test forehead, cheeks and jaw on each side for pain sensation, using sharp/dull • isolated facial sensory loss in peripheral nerve disorders like trigeminal neuralgia • if find an abnormality confirm it by testing temp sensation • test for light touch using fine wisp of cotton • test corneal reflex, touch cornea lightly with fine wisp of cotton • look for blinking eyes, normal reaction to this stimulus • absent blinking from CN V or VII lesion • absent blinking and sensorineural hearing loss in acoustic neuroma |
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CN VII
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• VII - facial
• ask pt to raise eyebrows, frown, close both eyes tightly so that you can’t open them, show upper and lower teeth, smile, puff out both cheeks • flattening of nasolabial fold and drooping of lower eyelid suggest facial weakness • peripheral injury to CN VII, as in Bell’s palsy, affects both upper and lower face; central lesion mainly affect lower face • loss of taste, hyperacusis, increased or decreased tearing also in Bell’s palsy • in unilateral facial paralysis, mouth droops on paralyzed side when pt smiles |
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CN VIII
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• VIII - acoustic
• whispered voice test • determine if loss is conductive (“air through ear” transmission) or sensoriuneural (damage to cochlear branch of CN VIII) • test for air and bone conduction (Rinne) and lateralization (Weber) Nervous System• vertigo with hearing loss and nystagmus in Meniere’s disease |
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CN IX and X
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• IX and X - glossopharyngeal and vagus
• listen to pt voice • hoarseness in vocal cord paralysis; nasal voice in paralysis of palate • difficulty swallowing? • pharyngeal or palatal weakness • ask pt to say “ah” - soft palate normally rises symmetrically, uvula remains midline • palate fails to rise with bilateral lesion of vagus nerve • in unilateral paralysis, one side of palate fails to rise and together with uvula, is pulled toward normal side • test gag reflex • unilateral abscense is lesion of CN IX or CN X |
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CN XI
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XI - spinal accessory
• ask pt to shrug both shoulders • trapezius weakness with atrophy and fasciculations indicates peripheral nerve disorders • trapezius muscle paralysis, shoulder droops, and scapula is displaced downward and laterally • ask pt to turn head to each side against your hand • supine pt with bilateral weakness of sternomastoids has difficulty raising head off pillow |
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CN XII
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• XII - hypoglossal
• listen to articulation of pt words • look for any atrophy of tounge • tongue atrophy and fasciculations in amyotrophic lateral sclerosis, polio • stick tounge out, move from side to side • unilateral cortical lesion, protruded tounge deviates transiently in a direction away from side of cortical lesions, toward side of weakness |
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a loss of muscle bulk or wasting
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• muscular atrophy refers to a loss of muscle bulk or wasting - results from diseases of
PNS like diabetic neuropathy |
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increase in bulk with proportionate strength
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• hypertrophy is increase in bulk with proportionate strength, whereas increased bulk
with diminished strenght is called pseudohypertrophy |
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atrophy
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flattening of thenar and hypothenar eminences and furrowing between metacarpals
suggest atrophy - localized atrophy of thenar and hypothenar eminences in median and ulnar nerve damage • causes of muscular atrophy in motor neuron diseases, RA and protein-calorie malnutrition fasciculations with atrophy and muscle weakness suggest disease of peripheral motor unit |
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when normal muslce with intact nerve supply is relaxed voluntarily it
maintains slight residual tension known as____________________ |
muscle tone: when normal muslce with intact nerve supply is relaxed voluntarily it
maintains slight residual tension known as muscle tone |
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decreased resistance
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• decreased resistance in disease of PNS, cerebellar disease or acute stages of SCI
• if u suspect decreased resistance, hold forearm and shake it, shouldn’t be floppy • marked floppiness in muscle hypotonia or flaccidity |
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increased resistance
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if resistance increased, feel for any jerkiness
• spasticity is increased resistance that worsens at extermes of range • spasticity in central corticospinal tract dieases • rigidity is increased resistnace throughout range of movement and in both directions |
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muscle strength testing
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• muscle strength - test by asking pt to move actively against your resistance
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impaired strength is called ________ or ___________
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impaired strength is called weakness or paresis
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paralysis, or plegia is
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absence of strength is called paralysis, or plegia
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scale for grading strength
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scale for grading
• 0 - no muscular contraction detected • 1 - a barely detectable flicker or trace of contraction • 2 - active movement of body part with gravity eliminated • 3 - active movement against gravity • 4 - active movement against gravity and some resistance • 5 - active movement against full resistance without evident fatigue (normal) |
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weakness of extension
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test flexion and extension at elbow by having pt pull and push against your hand
• test extension at wrist by ask pt to make a fist and resist you pulling it down • weakness of extension is seen in peripheral nerve disease like radial nerve damage and in CNS disease producing hemiplegia, as in stroke or MS |
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Testing grip
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test flexion and extension at elbow by having pt pull and push against your hand
• test extension at wrist by ask pt to make a fist and resist you pulling it down • weakness of extension is seen in peripheral nerve disease like radial nerve damage and in CNS disease producing hemiplegia, as in stroke or MS |
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• test finger abduction
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• test finger abduction - spread fingers open
• weak finger abduction in ulnar nerve disorders |
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• test opposition of thumb
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• test opposition of thumb
• weak oppostion of thumb in medial nerve disorders like CTS |
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test flexion of hip by
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• test flexion of hip by placing hand on pt thigh and ask pt to raise leg against your hand
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test adduction at hips by
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test adduction at hips by place hand firmly on bed between pt knees, ask pt to bring
knees together |
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symmetric weakness of proximal muscles suggest
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• symmetric weakness of proximal muscles suggest myopathy or muscle disorders
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• symmetric weakness of distal muslce suggest
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• symmetric weakness of distal muslce suggest a polyneuropathy, or disorder of
peripheral nerves |
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coordination requires _____ areas of nervous system to be functioning
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coordination requires 4 areas of nervous system to be functioning
• motor system for strength • cerebellar system for rhythmic movement and steady posture • vestibular system, for balance and coordinating eye, head and body movements • sensory system for posture sense |
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in cerebellar disease look for
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nystagmus, dysarthria, hypotonia, ataxia
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rapid alternative movements
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rapid alternative movements - hand on thigh then flip over, observe speed, rhythm and
smoothness • in cerebellar disease, one movement can’t be followed quickly by its opposite and movement are slow, irregular and clumsy - dysdiadochokinesis • UMN weakness and basal ganglia disease may also impair RAM |
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point to point movements
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• finger to nose test: ask pt to touch your index finger then their nose alternating
• cerebellar disease, movements are clumsy, unsteady and inappropriately varying in their speed, forcce and direction • the finger may initially overshoot its mark, but finally reaches it fairly well, dymetria • an intention tremor may appear towards end of the movements • cerebellar disease causes incoordinateion that worsesn with eyes closed - suggests loss of position sense • repetitive and consistent deviation to one side, referred to as past pointing, worse with eyes closed, suggest cerebellar or vestibular disease |
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heel to shin
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• heel to shin test
• in cerebellar disease, heel may overshoot the knee and oscillate from side to side down shin • when position sense is lost, heel is lifted too high and pt tried to look |
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romberg test
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romberg test: close both eyes for 30 to 60 secs
• in ataxia from dorsal column disease and loss of position sense, vision compensates for sensory loss • pt stands fairly well with eyes open but loses balance when closed = +test • cerebellar ataxia, pt has difficulty standing with feet together whether eyes are open or closed |
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pronator drift
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• pronator drift: stand with both arms straight forward with palms up, eyes closed
• pronator drift is pronation of one forearm • both sensitve and specific for corticospinal tract lesion orginiating in contralateral hemisphere • downward drift of the arm with felxion of fingers and elbow may occur |
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absence of pain sensation
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analgesia refers to absence of pain sensation
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hypoalgesia vs hyperalgesia
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hypalgesia decreased sensitivity to pain
hyperalgesia increased sensitivity |
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• light touch
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• light touch: with cotton wisp
• anesthesia is absence of touch sensation, hypesthesia decreases sensation; hyperesthesia increase sensitivity |
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vibration
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• vibration: use tuning fork on heel
• vibration sense is often the first sensation to be lost in peripheral neuropathy - common causes include DM and alcoholism • vibration sense is also lost in posterior column disease as in tertiary syphillis or vit B12 deficiency |
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proprioception
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proprioception (position): grasp pt big toe holding it by its side and then pull it away from
other toes, ask pt to respond if moving it up or down • loss of position sense in tabes dorsalis, MS, vit B12 deficiency |
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stereognosis
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stereognosis: ability to idnetify an object by feeling it
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asterognosis
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asterognosis: inability to recognize objected placed in hands
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• number identification
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: draw large number in person palm
• inability to recognize numbers suggest lesion in sensory cortex |
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deep tendon reflexes
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bicep reflex
• tricep reflex • supinatory or bachioradialis reflex • knee reflex • ankle reflex |
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grading of reflexes
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4+ very brisk, hyperactive with clonus (rhythmic oscillations between flexion and
extension) • 3+ brisker than average; possibly but not necessarily indicitive of disease • 2+ average, normal • 1+ somewhat diminished; low normal • 0 no response |
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slowed relaxation phase of reflexes in__________________seen easily in ankle
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slowed relaxation phase of reflexes in hypothyroidism seen easily in ankle
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ankle clonus
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• clonus: if ankle reflex hyperactive test for ankle clonus
• support knee in partly flexed position, with other hand dorsiflex and plantar flex foot a few times then sharply dorsiflex foot and maintain it in dorsiflexion • sustained clonus indicates central nervous system disease |
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abdominal reflexes
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• abdominal reflexes: lightly but briskly stroking each side of abdomen
• abdominal reflexes may be absent in both PN and CN disorders |
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plantar response
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plantar response
• stroke lateral aspect of sole from heel to ball of the foot, note movement of big toe • dorsiflexion of big toe is + Babinski response from CNS lesion in corticospinal • also seen in uncouscious states from drug or alcohol intoxication or postictal period following seizure |
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Brudzinski sign
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• Brudzinski sign: as flex neck, watch hips and knees in reaction to maneuver
• flexion of hips and knees is a + sign and suggest meningeal inflammation |
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Kernig
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Kernig sign: flex pt leg at both hip and knee, straighten knee, discomfort behind knee
during full extension occurs in many normal people should not produce pain though pain and increased resistance to extending knee = +sign, when bilateral suggest meningeal irritation |
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asterixis
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• asterixis: ask pt to “stop traffic” by extending both arms, with hands cocked up and fingers
spread • sudden, brief, nonrhythmic flexion of hands and fingers indicates asterixis, seen in liver disease, uremia and hypercapnia |
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comatose patient
• five clinical signs strongly predict death or poor outcome |
• absent corneal response
• absent pupillary response • absent withdrawl response to pain • no motor response • at 72 hours - no motor response • don’t dilate pupils • dont flex neck if any question of trauma |
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LOC: 5 types
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alertness: speak to pt in normal tone of voice, alert pt opens eyes, looks at you and
responds fully and appropriately to stimuli • lethargy: speak to pt in loud voice • lethargic pt appears drowsy but opens eyes and looks at you, responds to questions and then falls asleep • obtundation: shake pt gently • obtunded pt opens eyes and looks at you, but responds slowly and is somewhat confused, alertness and interest in environment are decreased • stupor: apply a painful stimulus • around from seelp only after painful stimuli, verbal response are slow or even absent, pt lapses into an unresponseive state when the stimulus ceases, min awareness of self or environment • coma: apply repeated painful stimuli • remains unarounsable with eyes closed, no evident response to inner need or external stimuli |
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• ocular movement
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• ocular movement
• in structural hemispheric lesions, eyes “look at the lesion” in affected hemisphere • in irritative lesions from epilepsy or early cerebral hemorrhage, the eyes look away from affected hemisphere • in comatose pt with absence of doll’s eyes movement, the abiliuty to move both eyes to one side is lost, suggest a lesion of midbrain or pons |
