Neurology Semiology

Front 1

Abnormal response to the corneal reflex test signifies what?

Back 1

lesion in the pons (CN V) - not a good test of CNVII b/c muscle power is poorly assessed

Front 2

What is the Doll's eyes test examining?

Back 2

oculocephalic reflex = tests integrity of brainstem, semicircular canals, and CN VIII.

Nucleus is at the pontine-medullary junction.

Should only be performed on comatose patients.

Front 3

What does an abnormal Doll's eye test indicate?

Back 3

Failure for eyes to move suggests brainstem damage - esp following:

- cardiac arrest

- large strokes

- followed up with iced water lavage of ear canals may be indicated

Front 4

What does the Romberg Test examine?

Back 4

truncal proprioception mediated by posterior columns of spinal cord

Front 5

What does an abnormal test indicate?

Back 5

Patients with cerebellar disease are unsteady with eyes open. Can't properly say that the patient has a (+) Romberg test

Front 6

What are the 3 different kinds of stroke etiologies? What are the major sources for the last etiology?

Back 6

1. subarachnoid hemorrhage (5%)

2. Primary intracerebral hemorrhage (15%)

3. Ischemic stroke (80%)

- artheroembolism (5%)

- intracranial small vessel disease (25%)

-cardiac source of embolism (20%)

Front 7

How does a cortical stroke present? What vessels are blocked?

Back 7

Carotid arteries.

Often presents with unilateral deficit in middle cerebral artery territory. Usually have combined motor and sensory deficits. Face and Hand often involved together - leg spared. With speech deficit or difficulty

Will spare motor function of forehead, jaw and tongue (bilateral innervation) in contrast with Bell's Palsy.

Graphestesia abnormal on involved side = cortical function processing sensory input.

Front 8

How does a lacunar CVA present? What vessels are blocked?

Back 8

Occlusion of small penetrating vessel serving white matter fiber projections. Often pure motor or sensory deficits that may involve leg, hand and face. Larger area b/c radiation of white matter projections.

Will spare motor function of forehead, jaw and tongue (bilateral innervation) in contrast with Bell's Palsy.

Front 9

What is a TIA?

Back 9

Transient ischemic attack. Stroke lasting <24h.

Front 10

How do you test for subtle motor weakness from stroke?

Back 10

Pronator drift. Hold arms out with palms up and closes eyes.

Supination is weaker than pronation, the involved arm with fall with simultaneous pronation.

A positive pronator drift suggests an upper motor neuron lesion.

Arm rising suggests impaired proprioception or cerebellar disease. (weak arms drop not rise)

No pronating suggests malingering or psych abnormality.

Front 11

What does discriminative sensation examine?

Back 11

Contralateral cerebral cortex processing of sensation.

Identify object placed in hand (stereognosis).

Identify number written in palm as patient would (graphesthesia)

Front 12

How is speech best tested?

Back 12

Having a conversation.

Having the patient repeat phrases (methodist-episcopal)

Having the patient name common objects presented to him.

Front 13

Dysarthria

Back 13

Disorder of coordination of muscles of speech; causes include:

- cortical stroke

- cerebellar disease

- peripheral neuropathy

Front 14

Expressive aphasia

Back 14

Difficulty forming words with preserved understanding; caused by lesion in inferior frontal cortex near motor strip (Broca's area = speech). Speech centers are located in the dominant cerebral hemisphere.

Front 15

Receptive aphasia

Back 15

fluent speech devoid of meaning due to lack of comprehension of language; caused by lesion in superior temporal lobe near auditory cortex (Wernicke's area = understanding)

Front 16

What does a deep tendon reflex examine?

Back 16

function of peripheral nerve and motor unit.

Front 17

What do hyperactive and hypoactive reflexes suggest?

Back 17

hyperactive = suggest CNS disease due to loss of upper motor neuron inhibition

hypoactive reflexes seen with neuropathy, motor neuron diseaes and neuromuscular junction disease (myasthenia graves)

Front 18

Name each of the spinal nerves for the reflexes below:

- ankle

- knee

- brachioradialis

- biceps

- triceps

Back 18

- ankle = S1

- knee = L 2-4

- brachioradialis = C 5-6

- biceps = C 5-6

- triceps = C 6-7

Front 19

What are each of the grades of DTR?

Back 19

0 = absent

1 = diminished, may require reinforcement to elicit

2 = normal

3 = brisk; may have 1-3 beats of clonus

4 = brisk with repeated clonus

Front 20

What spinal level does the plantar reflex correspond to? What is an abnormal response?

Back 20

L5-S1

Extensor. Fanning of toes may occur (Babinski response) indicates UMN - cortical stroke (unilateral), spinal cord disease (B12 deficiency, severe intoxication, post-octal state) (bilateral)

Front 21

What is the significance of babinski response?

Back 21

UMN disease. Including:

- cortical stroke

- spinal cord disease of multiple etiologies including (B12 deficiency, severe intoxication, post-ictal state)

Front 22

What does unilateral weakness suggest?

Back 22

most likely a stroke syndrome. Exclude unilateral cord disease.

Front 23

What does generalized weakness suggest?

Back 23

Toxin, electrolyte disorder, cervical cord disease, neuropathy, myasthenia, ALS.

Front 24

Compare UMN to LMN in terms of:

- muscle involvement

- muscle atrophy

- muscle tone

- DTR

- plantar reflexes

- clinical example

Back 24

Front 25

Describe each of the strength grades 0-5.

Back 25

0 = no contraction detected

1 = trace activity; unable to move joint

2 = able to move joint; unable to oppose gravity

3 = able to oppose gravity

4 = subnormal but can oppose some resistance

5 = normal

Front 26

Palmomental reflex (Frontal release sign)

Back 26

Stroking thenar imminence produces contraction of mentalist muscle.

Front 27

Suck reflex (Frontal release sign)

Back 27

sucking movement elicit with touching or stroking lips

Front 28

Snout reflex (Frontal release sign)

Back 28

puckering or protrusion of lips elicited by percussion of lips near midline

Front 29

grasp reflex (Frontal release sign)

Back 29

unrecgonized stroking of palm produces grasp fo fingers

Front 30

Resting tremor

Back 30

"Pill-rolling" tremor of Parkinson's disease. It occurs in posture of repose and is suppressed with activity, disappears with sleep.

Front 31

Intention tremor

Back 31

Cerebellar disease. Appears with action and worsens as goal is reached. Consider further assessment of rapid alternative movements (abnormality = dysdiadockokinesis) and point-to-point testing (overshooting = dysmetria)

Front 32

Postural (or action) tremor

Back 32

Finer an higher frequency tremor indicating a hyperadrenergic state. Becomes evident with action. Causes include:

- severe anxiety

- hyperthyroidism

- sympathomimetic drugs of abuse (amphetamine)

- alcohol and drug withdrawal

- essential tremor

Front 33

what is the more sensitive testing for gait?

Back 33

Tandem walk. Can also do normal walk.

Front 34

Cerebellar ataxia

Back 34

wide-based said, unsteadying, lateral veering.

Multiple sclerosis. Tumor.

Front 35

Sensory ataxia

Back 35

"stamp and stick" gait, looks at ground, feel ground through

B12 deficiency. Tabes Dorsalis.

Front 36

Festinating

Back 36

shuffling steps with rigidity, lower body appears to be chasing upper body

Parkinsons.

Front 37

Steppage or equine.

Back 37

inability to dorsiflex.

Trauma to peroneal nerve. Charcot-marie-tooth.

Front 38

What is the plamomental test?

Back 38

Asses for frontal lobe pathology. Alzheimer's disease. Dementia.

Front 39

Compare Cortical vs Lacunar Stroke on

- pathogenesis

- pathological target

- clinical findings

- other exam findings

- forehead motor function

- altered sensorium

Back 39

Front 40

Back 40

Peripheral CNVII lesion (Bell's Palsy) = one-sided facial weakness including frontal muscle (inability to raise eyebrow). NOT a parenchymal stroke - in which the frontal muscle receives bilateral UMN input and will be spared.

Most common cause is viral infection +/- an autoimmune reaction, sarcoidosis, lyme disease, acute HIV infection.

Front 41

What are Myasthenia graves symptoms?

Back 41

- involves bulbar muscles initially

- diplopia

- speech alterations

- ptosis

NOT urinary incontinence, blindness and vertigo are not features of MG

Front 42

What are the symptoms of Guillian-Barre?

Back 42

- ascending paralysis involving legs initially

- myopathy involving large proximal muscles (deltoid, thigh muscles)

Front 43

Generalized and Bilateral motor weakness etiologies

Back 43

- spinal cord disease (osteophyte, anterior cord infarction, transection)

- motor neuron disease (ALS)

- demyelinating disease (Guillian-Barre)

- motor end-plate disease (Myasthenia)

- myopathy (polymyositis)

Front 44

Unilateral and/or focal motor weaknesses etiologies

Back 44

- carotid artery distribution cortical stroke

- traumatic injury/nerve entrapment

- unilateral spinal cord disease

- lacunar stroke

Front 45

Posterior column disease findings

Back 45

- loss of both vibratory sensation and a wide based gait (sensory ataxia)

- positive Romberg test

Front 46

Parkinson's Disease findings

Back 46

- bradykinesia = slow movements

- mask-like facies = paucity of facial expression, reduced blinking and smiling

- changes in speech = may be soft and rapid with slurring, more monotone than usual

- poor balance and stooped posture

- micrographia = small handwriting

- rigidity = classically cog wheeling or lead-pipe (in contrast to clasp-knife rigidity of UMN disease)

- resting tremor = classic pill-rolling tremor in posture of repose and suppressed with activity

- Festinating gait = shuffling steps with rigidity

Front 47

Syringomyelia

Back 47

Central spinal canal enlargement usu in cervical cord.

Produces bilateral pain/temperature sensory loss and weakness in upper extremities due to damage to anterior horn cells with reduced/absent reflexes (lower motor neuron disease)

Front 48

• Bell’s palsy

Back 48

an idiopathic disorder of the Facial nerve (CN 7) producing unilateral facial weakness including an inability to close the eye.

Front 49

• Bilateral ptosis

Back 49

unusual finding that signals neuromuscular weakness; disorders to consider include myasthenia gravis, Miller-Fisher variant of Guillain-Barre syndrome and botulism.

Front 50

• Corneal reflex

Back 50

using a cotton wisp the examiner’s hand approaches from lateral aspect (avoiding being seen) and lightly strokes the cornea over the sclera; this is predominantly a test of sensation via ophthalmic division of Trigeminal nerve (CN 5), but Facial nerve (CN 7) fibers involved in efferent limb of reflex.

Front 51

• Deep tendon reflexes

Back 51

test the peripheral nerve (e.g. lower motor neuron), motor unit and upper motor neuron input with 2+/4 being normal. Hyper-reflexive responses (≥3+/4) can be seen diffusely with hyperadrenergic states (e.g. hyperthyroidism, amphetamine use) and focally with upper motor neuron disease, as the latter exert an inhibitory effect on lower motor neurons. Hyporeflexia occurs with neuropathy, acute spinal disease, lower motor neuron damage/disease and neuromuscular junction disease such as myasthenia gravis (and poor technique).

Front 52

o Clonus

Back 52

the term given to repeated contraction after elicitation of the deep tendon reflex, indicating extreme hyper-reflexia (aka 4+/4)

Front 53

o Hypothyroidism

Back 53

associated with a slow relaxation phase of the deep tendon reflex.

Front 54

o Transient ischemic attack (TIA) may involve different mechanisms

Back 54

1) Low flow states due to large artery occlusion; 2) Small emboli, which can be from large artery or heart (two most common sources); or 3) Lacunar TIA from stenosis of a small penetrating vessel. The TIA may involve the anterior circulation (carotid arteries) or the posterior circulation (vertebral and basilar arteries), and the TIA symptoms will reflect such. By definition a TIA resolves within 24 hours and identifies a patient at high risk of stroke. It is essential that these patients be evaluated promptly.

Front 55

• Doll’s eyes (aka oculocephalic reflex)

Back 55

this is a test of brainstem, Vestibulocochlear nerve (CN 8) and semicircular canal function that should be performed in comatose patients only. Manually raise both eyelids and move the head side-to-side – the eyes should move in tandem; failure to do so implies damage to one or more of structures above.

Front 56

• Frontal release signs

Back 56

reflect primitive reflexes in patients with diffuse frontal lobe pathology (e.g. Alzheimer’s dementia). These include the palmomental reflex (stroking the thenar area of the hand causes a reflex contraction ipsilaterally of the orbicularis oris and mentalis muscles), suck reflex (sucking movements by the lips when they are stroked or touched), snout (puckering or protrusion of the lips with percussion) and grasp reflex (the examiners hand is placed softly into patient’s palm during distraction – stroking of the patient’s palm produces a grasp by the patient that persists with movement).

Front 57

o Cerebellar ataxia

Back 57

wide-based, unsteady, lateral veering (e.g. multiple sclerosis, tumor of cerebellum)

Front 58

o Sensory ataxia

Back 58

this abnormality is produced by a loss of proprioception, such that the patient substitutes visual and nociceptive clues in an attempt to maintain stability. This produces the “stamp and stick” gait with the patient looking at the ground, as described by Ramsay Hunt. Causes include B12 deficiency, tabes dorsalis and other causes of posterior column disease.

Front 59

o Festinating gait

Back 59

shuffling steps with rigidity; lower body appears to be chasing upper body – this is the classic gait of Parkinson’s disease.

Front 60

o Steppage or equine gait

Back 60

inability to dorsiflex foot (e.g. trauma to peroneal nerve, Charcot-Marie-Tooth disease)

Front 61

• Plantar reflex

Back 61

a nociceptive (aka painful) reflex commonly elicited by firmly stroking the plantar surface of the foot from posterior to anterior. The normal response is flexion of the toes. Extension (aka Babinski reflex) is normal in the newborn, but is otherwise pathologic, indicating a problem with upper motor neurons. Common etiologies include cortical stroke, spinal cord disease from B12 deficiency, and occasionally from drug-induced encephalopathy.

Front 62

o Triple flexion

Back 62

the ultimate Babinski reflex with extension and fanning of the toes, dorsiflexion at the ankle, and flexion at the knee and hip.

Front 63

• Pronator drift

Back 63

a test of subtle upper motor neuron disease (e.g. suspect cortical stroke with borderline weakness). The patient is instructed to hold arms out, palms upward and then close eyes. Patients with unilateral weakness have the effected limb drop with simultaneous pronation. Other diagnoses that may be suggested including, 1) malingering the involved limb drops without pronation and 2) posterior column disease; the involved limb may “search” for the other limb, such as by moving superiorly.

Front 64

• Romberg test

Back 64

tests posterior column function (e.g. position sense), initially used as a test of tabes dorsalis (tertiary syphilis). The patient is instructed to stand with feet together, and after stable to close eyes. Healthy persons can usually stand this way with eyes closed for 60 seconds

Front 65

o Postural (or action) tremor

Back 65

becomes evident with action and includes hyperadrenergic (e.g. cocaine use, hyperthyroidism), physiologic, alcohol withdrawal and essential tremor.

Front 66

o Resting tremor

Back 66

occurs in posture of repose and suppressed with activity; classic “pill-rolling” tremor of Parkinson’s disease (usually disappears with activity and complete relaxation).

Front 67

o Intention tremor

Back 67

appears with action and worsens as goal is reached; cause relates to cerebellar disease.