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CS TIPS_Neuro_2010

Frontal Lobe: Primary Motor Cortex (pre-central gyrus). Personality, intellect, executive function, and impulse control. Lesion=seizures, change in consciousness, paresis, paralysis.
Broca Aphasia comprehension, but difficulty in saying words (nonfluent). (Frontal Lobe).
• Parietal Lobe: o Sensory data o Lesion = impairment in skin sensation on contralateral side of body
• Occipital Lobe: o Primary Visual Cortex
• Temporal Lobe: o Primary Auditory Cortex o Hearing, language, taste, smell, balance, behavior, emotions o Wernicke’s Aphasia – Poor comprehension, but NO difficulty in saying words even though they are said in a meaningless way (word salad)
• Limbic System: o Primarily composed of the Hypothalamus and Thalamus o Behavior patterns and emotions o Pneumonic – 5 F’s (feeding, fighting, feeling, fleeing, and …)
Wernicke's Aphasia Poor comprehension, but NO difficulty in saying words even though they are said in a meaningless way (word salad) (Temporal Lobe).
Cerebellum: • Controls muscle tone, equilibrium, and posture • Lesion = ataxia, postural abnormality, wide stance gait, imbalance, intention tremor, abnormal rapid-alternating-movements, impaired muscle tone and speech
• Lateral Spinothalamic Tract o Pain and Temperature
• Anterior Spinothalamic Tract: o Superficial touch and Deep pressure
• Posterior Columns: o Conscious proprioception, vibration, and light touch
• Spinocerebellar Tracts o Unconscious proprioception
• 5 Key Areas to the Neurologic Exam o Mental Status o Cranial Nerves o Motor-Coordination – Cerebellar o Sensory o Reflexes
Mental Status: Oriented in time, place, person.
• Mini Mental Status Exam o MMSE is normally a standardized 30 question form filled out with the patient. o Assess for cognitive changes
• Geriatric Depression Scale o Score greater than 5 suggests depression
o Confusion inappropriate response to questions, decreased attention span
o Lethargy drowsy when awakened, responds appropriately
o Delirium : confusion with disordered perceptions or anxiety with inappropriate reactions to stimuli
o Stupor: : arousable for short periods after visual, verbal, or painful stimuli
o Coma not awake and not aware • Glasgow Coma Scale – used in cases of head trauma or hypoxia (max score of 15) • The lower the score the more severe the impairment in consciousness (pg. 97)
• Apraxia patient has no motor deficits, but is unable to perform an activity
• Construct Apraxia – unable to construct or draw simple designs (clock face) o Lesion = Parietal Lobe
• Dyspraxia incompletely performs the activity o Lesion = Deep frontal lobe
CN I (Olfactory): • Test using a strong odor
CN II (Optic): • Visual Acuity using charts o Snellen – Large eye chart o Rosenbaum – Small (Hand-Held) eye chart • Ophthalmoscopic Exam • Sensory portion of the papillary light reflex
CN III (Oculomotor) / CN IV (Trochlear) / CN VI (Abducens): • Assess Size, Shape, and Symmetry • 6 Cardinal Fields of Gaze (H) • Confrontation or Peripheral Vision test • Accomodation
CN III (Oculomotor) / CN IV (Trochlear) / CN VI (Abducens): • Direct and Consensual Reflex • CN IV (Superior Oblique) • CN VI (Lateral Rectus) • CN III (All others) o Motor portion of the papillary light reflex o Constricts the pupil and elevates the eyelid
CN V (Trigeminal): • 3 divisions o CN V1 – Ophthalmic o CN V2 – Maxillary o CN V3 – Mandibular
CN V (Trigeminal): Testing Motor o Observe and say “I am looking for any muscle atrophy, deviation of the jaw, or fasciculations” o Clench Teeth  Palpate Temporal and Masseter muscles
Trigeminal Sensory testing o Ask patient to close eyes o Assess patient’s ability to feel light touch on forehead, cheeks, and jaw bilaterally
Corneal Reflex Tests CN V and CN VII o Sensory Limb – CN V1 o Motor Limb – CN VII
CN VII (Facial): Sensory o Taste to anterior 2/3 of tongue
Facial Nerve Motor o Raise eyebrows / close eyes tightly – you try to open/close o Smile using teeth, frown, puff cheeks out
Facial Upper and Lower Motor Neuron Lesion • Upper Motor Neuron Lesion – Stroke o Normal function to upper face o Contralateral weakness of lower face • Lower Motor Neuron Lesion – Bell’s Palsy o Total involvement of ipsilateral face paralyzed
CN VIII (Acoustic/Vestibulocochlear): • Be to sure always make sure the canals are open using your Otoscope • Assess Hearing using fingertips moving • Weber-Rinne Test o Weber – Patient should hear both sides equally (lateralization is a bad finding) o Rinne – AC > BC (2:1 ratio)
CN IX (Glossopharyngeal): • Sensory Function Testing: o Taste to posterior 1/3 of the tongue o Sensory portion of the Gag Reflex • Motor Function Testing: o Swallowing
CN X (Vagus): •Ability to swallow, Quality of speech, Inspect palate and uvula •Lesion = Uvula deviates away from the side of the lesion. Example – Ask patient to say “ah” and observe the uvula. The uvula deviates to the left. Lesion is on right CN X
CN XI (Spinal Accessory): Test • Shoulder shrug (Trapezius) and head turn (Sternocleidomastoid) – Be sure to always grade muscle strength (0-5 scale)
CN XI Scale 0-2 0 (absent): no contraction detected. 1 (trace): slight contraction. 2 (weak): movement with gravity eliminated.
CN XI Scale 3-5 3 (fair): movement against gravity. 4 (good): movement against gravity with some resistance. 5 (normal): movement against gravity with full resisance.
CN XII (Hypoglossal): Tongue movement and protrusion. Check tongue at rest for atrophy and fasciculations Lesion = Tongue deviates toward the side of the lesion Example – Ask patient to stick out their tongue, their tongue deviates to the left. Lesion in on the left CN XII
• Finger-Nose-Finger o Tests coordination and Fine Motor Skills o Patient’s eyes are open o Ask patient to touch their nose with their index finger
• Heel-Shin o Tests coordination and Fine Motor Skills o May perform sitting, standing, or supine o Run heel of one foot up and down shin of opposite leg
• Tandem Gait o Patient walks heal to toe
• Rapid Alternating Movements o Tests coordination and Fine Motor Skills o Alternately turn palms up and down o Must test for at least 20 seconds
• Romberg o Tests balance o Patient’s eyes first open and then closed o Ask patient to stand with feet together and arms at the sides. Be ready to catch patient
Dermatomes: • Band of skin innervated by the sensory nerve root of a single spinal segment • Carpel Tunnel – Median Nerve palsy – Use Tinnel’s and Phalen’s Tests
Sensory: Cerebellar • Perform with touch, pain, deep pressure, and vibration
• Peripheral Neuropathy o Disorder of the peripheral nervous system (PNS) that results in motor and sensory loss in the distribution of one or more nerves, most commonly the hands and feet. Sensation of numbness, tingling, burning, and cramping Commonlyassociated with Diabetes
• Stereognosis o Ability to recognize and identify familiar objects that are placed into the patients hand without them seeing the object
• Two-Point Discrimination o Alternate touching the patient with 1 and 2 points of sterile needles o Find the distance in which the patient is unable to discriminate two points
• Graphesthesia o Using a blunt pen or applicator stick, draw a letter or number on the palm of the patient’s hand o Patient should be able to identify the figure drawn
Conditions that may cause diminished reflexes include: • Anterior Horn Cell Pathology • Myopathies • Hypothyroidism
Conditions that may cause brisk/clonus reflexes include: • Pyramidal Tract Disease • Hyperthyroidism • Pre-Eclampsia (condition during pregnancy that includes high blood pressure, proteinuria, and edema) • Metabolic Disorders
• Deep Tendon Reflexes that are Hyperactive: o Upper Motor Neuron Disorder
• Deep Tendon Reflexes that are Absent: o Neuropathy or Lower Motor Neuron Disorder
• Deep Tendon Reflexes: o Biceps and Brachioradial  C5 – C6 o Triceps  C6 – C7 – C8 o Patellar  L2 – L3 – L4 o Achilles  S1 – S2
Babinski Stroke the lateral sole of the foot and move in a “J” motion towards the forefoot
Chaddock Stroke the lateral foot
Schaeffer Squeeze the Achilles tendon
Oppenheim – Press knuckles on skin and move distal
Gordon Squeeze calf briefly
Bing – Multiple light pinpricks on the dorsolateral foot surface
Gonda / Stransky Pull the 4th toe outward and downward briefly and quickly release o Bad sign if patient has:  Up Going Toes or Sustained Ankle Clonus
Gait: Stroke: o Spastic Hemiparesis  Affected leg is stiff and extended with plantar flexion of the foot. Foot is dragged, scraping the toe. Affected arm is flexed and adducted and does not swing.
Gait: Parkinson’s: o Shuffling  Posture is stopped and body is rigid. Steps are short with hesitation on starting and stopping.
Gait: Cerebellar: o Wide stance, staggering, and lurching from side to side. Accompanied by swaying of the trunk
Gait: Tabes: o Foot slapping
Gait: Sensory o Wide stance, with foot being brought down on heel then toe o Positive Romberg
o Wide stance, with foot being brought down on heel then toe o Positive Romberg o Flex the neck forward o Positive Sign – Involuntary flexion of the hips and knees when flexing the neck o Indicates – Meningeal Irritation
Meningeal Irritation: possible meningitis diagnosis Kernig’s Sign: o Flex the leg at the knee and hip when the patient is supine and then attempt to straighten the leg o Positive Sign – Pain in the lower back and resistance to straightening the leg at the knee o Indicates – Meningeal Irritation
Created by: ankurshah
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