neuro eval lecture 5b

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neuro eval lecture 5b
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2012-10-18 18:50:00
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neuro eval lecture 5b
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  1. -arthria
    control of speech
  2. asking pt to say "No ifs, ands, or buts," tests for what?
    Broca's aphasia
  3. dysarthria
    • some weakness or dyscoordination, spasticity, or hypotonia affection production of speech
    • it's a control problem, a motor problem, not a proplem of lang or comprehension 
  4. some possible causes of dysarthria
    lisp, stutter, bit or burnt tongue causing blurry speech, missing teeth, cerebellar impact on breath control, etc

    the big thing to remember here is it's the motor mechanism that's impaired, nothing about language or comprehension - that's aphasia
  5. dysphagia
    • difficulty w swallowing
    • (don't confuse this with dysarthria - a motor problem w speech)
  6. ataxic dysarthria
    • often sounds intoxicated (overshooting)
    • due to cerebellar problems
  7. what is affected by dysarthria?
    phonaon, respiratio, resonance, prosity of speech, intonation, articulation
  8. dysphonia
    hoarseness or low quality of boice production
  9. aphonia
    • inabilty to speak
    • often w bilateral damage to recurrent laryngeal nerves
  10. aphasia - CNS or PNS?
    dysarthria - CNS or PNS?
    • aphasia: always CNS
    • dysphasia: either
  11. MIT
    melodic intonation therapy: patients are taught to sing their conversations
  12. Broca's aphasia - other names for it?
    • expressive aphasia: bc can't get words out
    • non-fluent aphasia: bc broken both w spoken and written language
  13. main features of Broca's aphasia
    comprehension intact but pt can't communicate - ranges from missing pronouns and connecting words (sounds "telegraphic) to total inability to make coherent sounds
  14. Broca's aphasia is seen in which populations? Which part of the nervous system was hurt?
    • common in stroke and TBI pts, rarely MS
    • not in SCI because it's
    • a cortical issue
  15. Wernicke's aphasia hits what pts?
    • stroke, TBI, occasionally MS
    • not SCI bc this, like Broca's is a cortical issue
  16. two other names for Wernicke's aphasia
    • receptive aphasia: bc pt doesn't understand others's speech
    • fluent aphasia: bc can get words out, though the words are meaningless
  17. how someone w Wernicke's aphasia presents
    • impaired comprehension of speech and writing
    • "word salad" or gobble-dee-gook speech and writing
  18. aphasia
    • a communication issue
    • difficulty using lang to communicate
    • always CNS issue
    • cortical issue
    • aphasia says nothing about the motor production, just about the way the pt is using the tools in the mouth... see, it's a communication, not a motor problem (dysarthria is a motor problem, dysphagia is difficulty swallowing)q
  19. 8 components of mental status
    • level of consciousness
    • orientation ot time, place, person
    • attention
    • concentration (able to attend to a task for a particular amouint of time)
    • judgement (common sense about veering into danger)
    • memory (number sequence, PT's name....)
    • ability to calculate (count in 3s...)
    • language
  20. 6 levels on the spectrum of consciousness
    • alert
    • lethargy
    • oabtunded
    • stupor
    • coma (semi or deep)
    • irreversible coma
  21. def of lethargy on the spectrum of consciousness
    • drowsiness o inattention
    • will wake up on command and participate for short interval of time
    • somnolence


    slow, but can encourage/motivate self
  22. def of obtunded on the spectrum of consciousness
    • difficult to arouse
    • when aroused is confused and disoriented
    • wavers btwn lethargy and stupor
  23. def of stupor on the spectrum of consciousness
    • great effort to arouse
    • has minimal physical and mental activity

    needs outside source to encourage self to wake up
  24. responds to noxious pain, does visual tracking, reactive pupils... in semi, deep, and irreversible coma?
    • semi - may respond to noxious pain (reflexes)
    • deep and irreversible - no visual tracking or reactive pupils
  25. def of coma on the spectrum of consciousness
    unable to arouse
  26. features of the semi-coma (light coma)
    • no response to verbal stim
    • responds to pain (pressure on nailbed)
    • no movement except decorticate or decerebrate posturing
    • wandering or disconjugate eye movement
    • decreased reflex activity (such as Babinski)
    • may make sounds
  27. what's the decorticate posturing you'll see in light coma?
    decorticate: lesion in premotor cortex or higher corticospinal tract

    withdrawal/flexion in UEs, ext in LEs
  28. where would decerebrate damage be in a coma pt?
    lesion in high brainstem at intercollicular area, midbrain, and pons
  29. how would decerebrate posturing look in a coma pt?
    ext of all extremities, hyperpronation of forearm, flex wrists
  30. why is decerebrate damage uncommon in coma pts?
    decerebrate damage hits the high brainstem and affects breathing and basic life functions, so a pt wounded here is more likely to die than go into coma
  31. features of deep coma
    • no consistent response to verbal or painful stim
    • no movement
    • decreased or sporadic reflexes
    • decreased respiration
    • pupillary abnormalities
    • eyes may be open, but no tracking
  32. features of irreversible coma
    • brain death
    • loss of cerebral autoregulation
    • intracranial circulatory arrest --> necrosis --> cesation of meaningful cerebral activity (ie, stop the flow of cerebrospinal fluied and you'll get brain necrosis)
    • flat EEG
  33. coma vigil
    • a special case
    • it's btwn irreversible and deep coma
    • increased DTRs + Babinski
    • no pupillary light reflex, but might visually track (tracking is somatically controlled)
    • appears awake by day and asleep at night, but no higher mental function
  34. other names for coma vigil
    • akinetic mutism
    • wakeful unresponsiveness
  35. locked in syndrome is caused by what damage
    • inerrption of corticobulbar and crticospinal fxn causing parlysis of lower cranial nerves and quadriplegia
    • basilar-pontine destruction or infarct
    • end stages of ALS (this purely affects motor nerves)
  36. techniques for testing decreased levels of consiousness
    • call pt name in normal or loud voice
    • light touch on arm
    • vigorous shake n shoulder
    • painful stim into nailbed finger or toe
    • noxious stim using sternal rub
  37. Glasgow Coma scale
    ordinal scale that describes pt's repose following vebal commands or painful stim
  38. Glasgo Coma Scale evaluates what responsiveness
    • eye opening
    • best verbal response
    • best motor response
  39. scoring of the Glasgow coma scale
    • max 15 points
    • coma </= 8 pts
  40. decorticate vs decerebrate responses to pain
    • decorticate: bilat withdrawal, body flexes inappropriately much to the pain
    • decerebrate: body becmes rigid in ext
  41. attention def
    ability to concentrate on a specific stim w/o being distracted by extraneous stim
  42. vigilance def
    ability to concentrate on a stim fr > 30 sec
  43. inattention def
    • looks at something but doesn't see it
    • can be clinical or specific
  44. clinical inattention def
    inability to pass a formal attention test, such as digit repetition or connect the dots (trail making) in an appropriate amount of time
  45. specific inattention def
    • inbility to notice two stim presented at thesame time
    • (like hearing the water boil while you're reading)
    • auditory: 1 sound/ear
    • visual: 1 stim / each field of vision (L/R)
    • tactile: 1stim/location on body (like the double simultaneous extinction test)
  46. polymodal vs unimodal interp of specific inattention
    • polymodal: all sensory modalities are affected
    • unimodal: just one
  47. common syndromes involving attention
    • anxiety and depression
    • difuse brain dysfunction
    • metabolic disturbances
    • post-surgical state of confusion
    • systmic infection
    • frontal lobe or limbic system (emotions) lesions
    • parietal lobe lesions (this lobe deals w sensory info)
    • right hemsphere lesions
  48. memory basic def
    reentin of learned info and experiences
  49. memory involves...?
    • attention to info,
    • encoding info,
    • storage of info,
    • retrieval of info
  50. pre-requisites for memory
    • hippocampus in food shape
    • cortical and subcrtical function
    • (bc mem is partly sensory, need healthy basal ganglia)
    • norml sensatons, motion, and lang
  51. stages of memory processing
    • input: register the specific sensory modality
    • hold it temporarily: short term mem - limbic system
    • store it: long term mem - limbic
    • recall it: limbic (this is why slep is important for memory - helps encode memories)
  52. 3 levels of memory
    • immediate: short term (seconds)
    • recent:day to day events, held a few hours
    • remote: long term memory - past events
  53. anterograde amnesia
    can't learn new info
  54. retrograde amnesia
    can't remember evens prior to CNS insult (TBI)
  55. psychogenic amnesia
    • block out a period of time
    • this is a dissociative state
  56. test for short term mem
    recall a short string of numbers or a poem
  57. test for recent memory
    tell pt 4 unrelated words and ask pt to recall them in 10 and 30 min
  58. test for remote memory
    • last 4 presidents
    • details from childhood
  59. alzheimer's disease - what's the impairment?
    new learning and recent mem are impaired
  60. Korsakoff's Syndrome
    thiamine deficiency assoc w ETOH abuse and malnutrition --> organic amnesiac state
  61. anxiety's influence on memory
    functional memory disturbances
  62. how to test judgement
    ask hypothetical q's about what pt would do in X situation (fire in the wastebasket....)
  63. how to test reasoning
    ask pt to explain a phrase "a rolling stone gathers no moss"

    reasoning: ability to draw conclusions and problem solve when dealing w abstract thoughts
  64. Mini Mental State Examination (MMSE)
    • 30 pt questionnaire
    • assesses congnition - orientation, registration, attention, calculation, lang, basic motor skills, memory
  65. scoring on the Mini Mental State Exam (MMSE)
    • out of 30
    • norm: 28-30
    • mild dementia: 20-26
    • mod dementia: 10-19
    • severe dementia: <10

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