Part 4 Boards - Neuro DX
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. What would you like to do?
What are you looking for with the 6 Cardinal Fields Of Gaze?
- "I'm looking for symmetrical movements & no nystagmus."
- *Lesion of IV (Sup Obl.): cannot go down & in.
- *Lesion of VI (Lat Rect.): cannot go laterally.
- *Make sure you are at the same eye level as the pt.
- *Pause for 1-2 seconds at each end range.
Testing the muscles of mastication is associated with which CN?
- V (Trigeminal): Temporalis, Int Ptyergoid, Masseter, Ext Ptyergoid.
- *Not tested: Jaw Jerk Reflex.
What are the 3 locations for sensory testing of CN V?
- 1. Forehead.
- 2. Cheekbones.
- 3. Chin.
- "Say yes when you can feel me touch your face."
- *Use cotton wisp, stay midline & do 6 points.
- *Not tested: Corneal reflex, oculocardiac reflex, general sensation to the ant 2/3 tongue.
_________: extreme, sporadic, sudden burning/shock-like face pain that lasts anywhere from a few seconds to 2 min/episode, is associated with which CN?
- Tic Douloureaux: Trigeminal Neuralgia = extreme, sporadic, sudden burning/shock-like face pain that lasts anywhere from a few seconds to 2 min/episode.
- *Typically felt on the L side of the face.
- *Made worse by moving the TMJ.
- *Refer/co-treat w/ neurologist.
The muscles of facial expression are associated with which CN?
- VII Facial: show your patieint what you want them to do (raise your eyebrows, close your eyes, puff out your cheeks, etc).
- *Also taste to the ant. 2/3 of tongue.
Bell's Palsy is associated with which CN?
- CN VII = Bell's Palsy: complete unilateral paralysis.
- *D/T trauma, virus or BC pills.
- *They give a pt HX of female 20-35 YO.
- *Ipsilateral ear, twitching, weakness/paralysis, drooping/eyelid, drooping of the corner of the mouth, drooling, dry eyes, decreased taste.
- *CN VII shuts the eye = NO corneal reflex.
- *Bell's Palsy is an inflammation problem = self-resolving.
LMNL's affect ______ of the face.
- LMNL's affect ALL of the face.
- *Bell's Palsy = LMNL of CN 7.
- *Forehead does not wrinkle.
_________: vertigo, hearing loss, tinnitius & fullness in the ear.
Meiniere's DX / Endolypmhatic Hydrops / Central Vertigo.
Which CN is associated with shoulder shrugging & head rotation?
- XI Spinal Accessory.
- *Traps: shoulder shrug.
- *SCM: LF & rotation.
- *Torticollis (Wry Neck): spasm of the SCM.
- *TX: transfriction massage, spray & stretch.
How do you test CN XII?
- Have the pt stick out their tongue.
- *Deviates to side of lesion.
Know UMNL vs LMNL.
- UMNL: MS, CVA, brain tumor, Parkinson's.
- LMNL: Subluxation, Myasthenia Gravis, NRC, disc protrusion, Polio, Bell's Palsy, ALS.
- *DX subluxation by ruling out everything else.
- *Pt is acting & will fake babinski response.
Pt HX for a CVA?
Female on BCP's, @ air show looking up or @ hair dresser before SX started.
MG SX's are ______ in the morning.
- MG SX's are better in the morning (worse at night).
- *Bilateral ptosis.
Describe a (+) Babinski's...
- Dorsiflexion of the great toe w/ splaying of the other toes.
- *If pt jerks foot away = plantar reflex.
- Test ALL reflexes bilaterally, w/ normal side first.
- *If you do not get a response pretend like you did & move on!
- *Normal: 2+.
What is the pt positioning for the Knee Jerk reflex?
- Pt seated, with your fist under their leg to support it from touching the table.
- *C5: Biceps.
- *C6: Brachioradialis.
- *C7: Triceps.
- *L4: Patellar (Knee jerk).
- *L5: Medial hamstring... do prone, bend knee to 30 degrees.
- *S1: Achille's (Ankle jerk).
How many mm's do you test for NR evlauations?
- Just one!!
- C5: Arm abduction.
- C6: Wrist extension.
- C7: Wrist flexion.
- C8: Make an 8.
- T1: Finger fun.
- L4: Up & in (dorsiflexion & inversion).
- L5: Big toe extension.
- S1: Down & out (plantar flexion & eversion).
- *Do L4-S1 mm tests w/ pt supine.
What 2 ways do you test dermatomes for boards?
- 1. Using a cotton ball; touch the dermatomes you are testing, asking the pt "does this feel like this?"
- 2. Using the cotton swab & tooth pick; alternate sharp dull sharp dull 3 x's per dermatome.
- *No sharp/dull for T1-12 dermatomes.
- *Call out what you are doing "I'm testing the C5 dermatome... Does this feel like this?"
- *Do cotton swab first.
Which 2 dermatomes are different for boards?
- 1. No big toe... just med aspect of the leg.
- 2. No post calf... just lat aspect of the foot & little toe.
- *Do bilaterally!
- *Anesthesia, hypoesthesia & hyperesthesia.
Verbal instructions for the pt w/ graphesthesia...
- "I am drawing a capital letter in your hand, so LMK what you feel."
- *Draw an A or a C.
What is sterognosis?
Put a familiar object in the pt's hand & ask them to identify it.
A (+) graphesthesia or sterognosis indicates a problem with...
"Inability to do this means a lesion of the dorsal columns."
Which 2 conditions are associated with a Median N lesion? Which fingers are affected?
- 1. CTS: lat 3 fingers.
- 2. Pronator Teres Syndrome: lat 3 fingers.
The use of a cock up splint is helpful for which condition?
Which 2 locations are associated with Ulnar N compression? Which fingers are affected?
- 1. Tunnel of Guyon (Pisi/Hook of Hamate): medial 2 digits.
- 2. Cubital Tunnel: medial 2 digits.
- *Claw hand deformity D/T hypothenar atrophy... "I'm going to CLAW yoU!"
What condition of the hand is associated with a Radial N entrapment?
- Wrist drop: inability to extend the elbow & wrist.
- *Decreased triceps reflex & sensation to the post arm.
Where does the pain present in a sciatic pt?
- The post. butt, thigh & leg down to the floor.
- *Weak knee flexion & decreased achille's reflex.
- *Allowed to adjust this pt!
TTS needs to be DDXed from which DX?
- *TTS = med plantar N entrapment behind the med malleolus = burning @ the bottom of the foot.
Where is the MC location for weakness associated w/ Syringomyelia?
- *Loss of sensation of pain & temp over the shoulders in a cape-like distribution.
- *Pt is a nurse, cleft palate repair when younger.
__________: diploplia, scotomas, transient blindness, optic neuritis, pain, vertigo & UMNL in the legs ([+] Babinski) causing dital weakness.
- *Heat exacerbates SX... remissions.
- *(+) Lhermitte's... "Where do you feel the pain?"
- *It's a SIN to have MS.
- *Charcot's Triad: Scanning speech, Intention tremors, Nystagmus.
- *DX via MRI, or CSF tap.
You walk into the room & notice that the pt is blinking excessively... what is your initial impression?
- "I noticed that you're blinking a lot. Anything going on with that?"
- *Affects the motor CN's first, then the prox mm's.
- *Early signs = ptosis, diplopia, dysarthria, weakness @ the end of the day & fatigue after exercise.
- *Females 20-40 YO.
- *DX via ACHr, TX w/ cholinesterase inhibiting drugs.
- *Eyes weak @ the end of the day = refer to neurologist.
Where does ALS usually begin?
- The hands or feet.
- *Males >40 YO.
- *Short life expectancy.
- *Fasiculations, spasticity & increased DTR's.
- *LMNL's in the arms, UMNL's in the legs.
- *DDX lat canal stenosis.
A/K/A for Extrapyramidal Tract Disorder?
- Parkinson's DX (Paralysis Agitans).
- *Female pt whispering, w/ finger rolling tremor & weakness.
- *Resting tremors, mask like face, festinating (propulsive/shuffle) gait, cogwheel/lead pipe rigidity, forward stooped posture, bradykinesia.
- *D/T loss of dopamine in the substantia nigra.
- "I see that your fingers are moving, can you tell me more about this?"
What does a pt w/ Guillain- Barre Syndrome present with?
- Weakness... send to ER!
- *Demyelnating polyneuropathy of the PNS D/T immunizations or recent illness.
- *Ascending paralysis & sensory SX.
What is the classic gait presentation for a pt with Paralysis Agitans?
- *Steppage = ACS, L4 lesion or TA problems.
- *Circumduction = stroke.
- *Wide based (drunken) = cerebellum.
What are the 3 a/k/a's for the common migraine?
- 1. Sick
- 2. Vascular
- 3. Hormonal
- *Photophobia, throbbing, worse behind one eye, nausea/vomiting, bright lights, red wine, menstural cycle, hypoglycemia.
- *Adjust, dietary log, massage, avoid triggers.
What type of HA presents with a prodrome?
Classic migraine = aura (prodrome).
Which type of headache is gone by noon?
2 A/K/A's for Cluster headache?
- 1. Autonomic Nervous System Distrubance.
- 2. Vasomotor headache.
- *HA lasting 15 min - hours w/ rhinorrhea, unilateral facial sweating, red eye, miosis.
- *R/O intracranial pathology.
- *Do CN CT scan & exam.
- *Allergy testing.
Which type of HA has a band-like presentation?
2 A/K/A's for Polymyalgia Rheumatica?
- 1. Temporal Arteritis.
- 2. Giant Cell Tumor.
- *Over 50 years old.
- *Unilateral, temporal.
- *Pain w/ combing hair.
- *DX via ^ ESR and biopsy.
A/K/A for Vertebrogenic headache?
- *Occipital/upper cervical region.
- *May occur daily.
- *Pt has decreased ROM & pain in neck.
- *F/E views to R/O congenital anomaly.
Which brian bleed has an abrupt onset?
- Subarachnoid hemorrhage.
- *Basilar area.
- *Stiff neck, excruciating pain like never before.
Which brain bleed has SX & SX's weeks post injury?
Meningial irritation is worse in which position?
- *(+) Kernig & Brudzinski Tests.
- *CSF tap: decreased sugar = bacterial, increased protein = viral.
Who do you refer to with hypoglycemic headaches?
What would you like to do?
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