Physical Diagnosis Midterm - Nervous System

Front 1

Spinal cord extends from

Back 1

Brainstem (medulla) to L1-L2

Front 2

Where are lumbar punctures most commonly performed

Back 2

L3-L4 or L4-L5

*The cauda equina is here*

Front 3

CN III-XII arise from?

CN I and II arise from?

Back 3

III-XII: diencephalon and brainstem

I and II: fiber tracts emerging from brain

Front 4

In the spinal cord what roles do the ventral and dorsal roots play?

Back 4

Dorsal = Sensory
Ventral = Motor

Merge together to form spinal nerve

Front 5

Dermatome

Back 5

Band of skin innervated by the single sensory root of a spinal nerve

Front 6

Nerve Cell bodies of UMN located where?

Back 6

Motor strip of cerebral cortex and brainstem
(Contralateral)

Front 7

LMN nerve cell bodies are located where?

Back 7

Ventral horn of spinal cord

Front 8

Where do UMN cross/decussate

Back 8

Medullary pyramids

Front 9

UMN lesions cause which symptoms?

Back 9

Hypertonia
Hyper-reflexia
Spasticity
Weakness
Paralysis

Front 10

LMN lesions cause which symptoms?

Back 10

Hypotonia
Hyporeflexia
Weakness
Paralysis
Atrophy

Front 11

UMN stroke vs. LMN stroke
Describe the face

Back 11

UMN: patients can close both eyes and elevate both eyebrows. Some LMNs are still receiving contacts so these functions are still in tact

LMN: patients cannot close ipsilateral stroke side and cannot crease the forehead above the stroke side. There is complete paralysis of the nerve

Front 12

What are the three main motor pathways

Back 12

Corticospinal
Basal ganglia system
Cerebellar system

Front 13

Function of corticospinal pathway

Back 13

Most important motor pathway.
Controls voluntary movements and integrates skilled/complicated/fine movements by stimulating some actions while simultaneously inhibiting opposing.
Cross at the Medulla

Front 14

Function of Basal Ganglia system

Back 14

Helps maintain muscle tone and control body movements.
(Especially gross movements as in walking)
Projects to cerebral cortex and brainstem to help control these movements

Front 15

Hallmark disease of the basal ganglia

Back 15

Parkinson's

Front 16

S/S of Parkinson's

Back 16

Hypertonia
Bent forward posture
Bradykinesia
Shuffling gait

Front 17

Function of Cerebellar System

Back 17

Receives sensory and motor input

Coordinates motor movements, maintains equilibrium and helps maintain posture

Front 18

What are the two main sensory pathways

Back 18

Spinothalamic Tract (anterolateral)

Posterior Column (dorsal column)

Front 19

Spinothalamic tract: where does it cross and what senses does it conduct?

Back 19

Crosses at the same level as it enter spinal cord

Pain, temperature, crude touch
(light touch)

Front 20

Posterior column: where does it cross and what senses does it conduct?

Back 20

Move upward first and cross at medulla

Discriminative (fine) touch, pressure, vibration, position (proprioception)

Front 21

ROS Questions for Nervous System

Back 21

Headache Dizziness or vertigo
Generalized, proximal, or distal weakness
Numbness Loss of sensation
Loss of consciousness, syncope, or near syncope
Seizures Tremors Involuntary movement

Front 22

Neurologic Exam is categorized into 5 systems
What are they?

Back 22

Mental Status
Cranial Nerves
Motor System
Sensory System
Reflexes

Front 23

What are the basic components of a mental status exam

Back 23

Level of alertness
Appropriateness of responses
Orientation to date, time, place person, current events
Language
Speech

Front 24

Proper Test for CN I; olfactory

Back 24

Occlude each nostril and test different smells

Front 25

Proper test for CN II; optic

Back 25

Test visual acuity with eye chart
Inspect fundi
Screen visual fields by confrontation

Front 26

Proper test for CN II and III; optic/oculomotor

Back 26

Inspect size and shape of pupils
test reactions to light and near response

Front 27

Proper test III, IV, VI; oculomotor, trochlear, abducens

Back 27

Test extraocular movements in 6 cardinal directions
Lide elevation
Check convergence

Front 28

Proper test for CN V; trigeminal

Back 28

Palpate temoral and masseter mm with clenched jaw
Test forehead, each cheek and jaw for sharp/dull/light
Test corneal reflex with cotton whisp on cornea
(pt should blink)

Front 29

If a patient has an absent corneal reflex and hearing loss, what is the probable diagnosis

Back 29

Accoustic neuroma

Front 30

Proper test for CN VII, facial

Back 30

Assess face for symmetry, tics, irregular movement
Have patient raise eye brows, frown, smile, and puff cheeks. You can also have them shut their eyes tightly against resistance.

Front 31

Definition of Bell's Palsy

Back 31

Lower motor neuron dysfunction of Facial Nerve
Paralysis of upper and lower face
(the frontalis muscle is commonly unable to perform normally-wrinkle forehead)
Usually transient

Front 32

Definition of Stroke (CVA)
According to CN VII

Back 32

Upper motor neuron dysfunction affecting CN VII
Paralysis of lower face with preservation of frontalis muscle and closing of the eye

Front 33

Facial nerve sensory testing

Back 33

Taste
Sweet, salty, sour, bitter
Not usually indicated

Front 34

Proper test for CN VIII, vestibulocochlear

Back 34

Sensory only
Whisper test with opposite tragus covered

Front 35

Conductive vs. Sensorineural hearing loss

Back 35

Air > bone = conductive
Bone > air = sensorineural

Front 36

Tests for conductive and sensorineural hearing loss

Back 36

Weber: Lateralization

Rinne: air and bone conduction

Front 37

Proper tests for CN IX and X; glossopharyngeal and vagus

Back 37

Ssay "Ah" (both, uvula is vagus)
Ask and inspect for swallowing (both)
Ask and listen for hoarseness (vagus)
Palpate cricoid
Gag Reflex (usually just glosso)
Taste (glosso)

Front 38

Proper test for CN XI; spinal accessory

Back 38

Motor only
Inspect for atrophy and symmetry of shoulders
Pt shrugs shoulder against resistance
Pt turns head side to side against resistance

Front 39

Proper test for CN XII; hypoglossal

Back 39

Inspect speech formation
Tongue atrophy and deviation

Front 40

Explain the patho behind tongue deviation

Back 40

Tongue deviates toward side of weakness

But the cortical defect is on the opposite side

Ex: Right tongue deviation = right XII nerve palsy = left cortical lesion

Front 41

Explain the patho behind uvula deviation

Back 41

Uvula deviates toward strong side

Cortical defect is on that side of the brain

Ex: Right uvula deviation = left X nerve palsy = right cortical lesion

Front 42

What are you looking for in the motor system
(five main categories)

Back 42

Body position
Involuntary movements
Inspect muscle bulk
Inspect muscle tone
Test muscle strength

Front 43

Define tremor

Back 43

Rhythmic oscillatory movement
1. resting
2. postural
3: intention

Front 44

Define Tics

Back 44

Repetitive, brief, stereotyped coordinated movement occuring at irregular intervals
Due to Tourette's, drugs, other..

Front 45

Define Dystonia

Back 45

Involves a larger portion of the body than tics.
Grotesque, twisted postures
Usually due to drugs

Front 46

Define Athetosis

Back 46

Slower and more twisting/writhing that chorea with larger amplititude. typically involves the face and distal extremities.

Ex: Cerebral Palsy

Front 47

Define Chorea

Back 47

Brief, rapid, jerking irregular and unpredictable movement. NOT PREDIBTABLE

Front 48

Pseudo-hypertrophy

Back 48

Increasing bulk without increasing strength

Ex: Duchenne's muscular dystrophy

Front 49

Define spacicity

Back 49

Hypertonia that is rate dependent
(resistance throughout ROM)

Front 50

Define paratonia

Back 50

Sudden changes in tone with passive ROM

Ex: due to dementia

Front 51

Scale for grading muscle strength

Back 51

0-5 (rather variable)
0--no muscular contraction detected
3--active movement against gravity
5--active movement against full resistance, no fatigue

Front 52

Nerves that innervate flexion of the elbow

Back 52

C5 & C6
biceps

Front 53

Nerves that innervate extension of the elbow

Back 53

C6 C7 & C8
triceps

Front 54

Nerves that innervate extension of the wrist

Back 54

C6 C7 & C8
extensor carpi radialis longus and brevis

Front 55

Nerves that innervate Grip

Back 55

C7 C8 & T1

Front 56

Nerves that innervate finger ABduction

Back 56

C8 & T1
Checking specifically the ulnar nerve

Front 57

Nerves that innervate opposition

Back 57

C8 & T1
Checking the medial nerve

Front 58

Nerves that innervate flexion of the hip

Back 58

L2 L3 & L4
iliopsoas

Front 59

Nerves that innervate ADduction of the hip

Back 59

L2 L3 & L4
adductors

Front 60

Nerves that innervate ABduction of the hip

Back 60

L4 L5 & S1
gluteus medius and minimus

Front 61

Nerves that innervate extension of the hip

Back 61

S1
gluteus maximus

Front 62

Nerves that innervate extension of the knee

Back 62

L2 L3 & L4
quads

Front 63

Nerves that innervate flexion of the knee

Back 63

L4 L5 S1 & S2
hamstrings

Front 64

Nerves that innervate dorsiflexion of the ankle

And Nerves that innervate plantar flexion

Back 64

Dorsi: L4 & L5
tibialis anterior

Plantar: S1
gastrocnemius and soleus

Front 65

Differentiate between Myopathy and Polyneuropathy

Back 65

Myopathy: symmetric weakness of PROXIMAL mm

Polyneuropathy: symmetric weakness of DISTAL mm

Front 66

Coordination exam includes

Back 66

Rapid alternating movements
Point-to-point movements
Gait

Front 67

Define ataxia

Back 67

A gait that lacks coordination and is unsteady. May be seen with cerebellar disease, loss of position sense, intoxication etc...

Front 68

Spastic hemiparesis is due a stroke where?
What does it look like?

Back 68

Corticospinal tract lesion
Affected arm is flexed and close to body
Affected leg extensors and spastic
Patients may drag toes in circumduction

Front 69

What does cerebellar ataxia look like

Back 69

Cerebellar disease

"intoxicated walking"
loss of coordination

Front 70

Steppage gait

Back 70

Seen in foot drop
Secondary to peripheral motor unit disease

Front 71

What is the Romberg test?

Back 71

Test of position sense
Stand up, hands palm up, eyes closed for 30-60 sec
Loss of balance when eyes are closed = positive

Indicated dorsal column disease

Front 72

Suggested pattern for tests such as pain, temp, touch

Back 72

shoulders
inner and outer forearms
thumbs and little fingers
fronts of thighs
medial and lateral calf
little toes
medial aspect of buttock

Front 73

Define Deep Tendon Reflexes (DTR)

Back 73

Reflex is involuntary sterotypical response that involves both sensory and motor neurons

Front 74

DTR grading system

Back 74

(2 is normal!!)
0--no response
1--somewhat diminished, low normal
2--average, normal
3--brisker that average, possibly indicative of disease
4--very brisk, hyperactive, clonus present

Front 75

Nerves that test reflex of: biceps

Back 75

C5 & C6

Front 76

Nerves that test reflex of: triceps

Back 76

C6 & C7

Front 77

Nerves that test reflex of: brachioradialis

Back 77

C5 & C6

Front 78

Nerves that test reflex of: knee

Back 78

L2 L3 & L4

Front 79

Nerves that test reflex of: ankle

Back 79

S1

Front 80

Define clonus

Back 80

Manual repeated doris- and plantar flexion of the foot is followed by involuntary rhythmic oscillation between these position on exam
(shows UMN disease)

Front 81

Babinski test is indicative of UMN or LMN disease?

Back 81

UMN!

When patient has Babinski sign, toes dorsiflex upon stimulation of lateral foot

Front 82

Loss of anal reflex is indicative of what disease?

Back 82

Cauda Equina syndrome

Front 83

Three test for meningitis

Back 83

Nuchal rigidity: resistance of neck movement
Brudzinski's
Kernig's sign

Front 84

Most common location for disk herniation

Back 84

L5-S1

Front 85

Lumbosacral Radiculopath has two positive tests, what are they?

Back 85

Positive straight leg test
Positve crossed straight leg test

Record the angles!
*both should produce pain

Front 86

Define axterixis test

Back 86

Hands held in "stop traffic" position for 1 minute

Seen in encephalopathy, liver disease, uremia, and hypercapnia

Front 87

Five levels of consciousness

Back 87

Alert
Lethargic
Obtunded
Stupor
Coma

Front 88

Glasgow coma scale
What are the three features of it
What is the score that is classified as a severe coma

Back 88

Checks for eye opening, verbal responses, and best motor responses
Highest score is 15
<9 is a severe coma
9-12 is moderate

Front 89

Main goal in dx of a comatose patient

Back 89

Decide whether it is metabolic or structural

Front 90

What do the pupils look like in a metabolic coma

Back 90

"the presence or absence of light reaction is one of the most important signs distinguishing structural form metabolic causes"

Metabolic: equal reactive to light

Front 91

What do the pupils look like in a structural coma

Back 91

"the presence or absence of light reaction is one of the most important signs distinguishing structural form metabolic causes"

Structural: unequal or unreactive to light-- "fixed"

Front 92

Oculocephalic Reflex
AKA Doll's eye movements

Back 92

Normal: eyes move opposite of the head motion

Positive: absence of the above when the head is moved side to side

*indicative of a lesion in the midbrain or pons

Front 93

Define decorticate rigidity

Back 93

Upper arms and joints are flexed
legs extended and internally rotated

Lesion in corticospinal tract

Front 94

Define decerebrate rigidity

Back 94

Jaws clenched, neck extended
Arms adducted and extended, forearms pronated
Legs extended

Lesion in diencephalon, midbrain,
Common in head trauma in football

Front 95

What is the 3rd leading cause of death in the US

Back 95

Stroke (CVA)

Front 96

Definition of Stroke (CVA)

Back 96

Sudden focal neurologic deficit cause by cerebrovascular ischemia or hemorrhage

Front 97

Define TIA (transient ischemic attack)

Back 97

Sudden focal deficit lasting <24 HOURS, and WITHOUT structural damage

Front 98

Which kind of stroke causes headach

Back 98

Hemorrhagic stroke causes severe headache

Ischemic does not

Front 99

Most common vessel for a stroke
What area of the brain is this in

Back 99

Middle cerebral Artery

Middle brain

Front 100

Define seizure

Back 100

Rhythmic!

Paroxysmal disorder caused by sudden excessive electrical discharge in the cerebral cortex or underlying structures. Usually indicate a structural lesion in the brain.

Front 101

What are the two types of partial seizures
AKA focal seizures

Back 101

1. Simple partial: no loss of consciousness
2. Complex partial: loss of consciousness followed by lethargy, stupor, AMS

Front 102

What are the two types of generalized seizures

Back 102

1. Tonic-clonic (gran mal): LOC, body stiffens into tonic extensor rigidity, Clonic phase of rhythmic muscle contraction
2. Absence: sudden brief lapse of scsciousness, with starring, blinking, lip movments

Front 103

Define Nystagmus

Back 103

Described by the direction of the FAST phase