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Year 3 - Clinical Communication Skills > Neuro Examination and History > Flashcards

Flashcards in Neuro Examination and History Deck (46)
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1

How to take a Neuro History

History of presenting compliant
- What have you come to see us with today?
- Do you have any other symptoms?
- How are you feeling at the moment
- How long has it gone on for
- Has this happened before and when did it start
- was the start of this pain associated with a specific event
- What does it (pain) feel like
- Do it start suddenly or a gradual onset
- Where speficially is the pain and does it spread
- What is the character of the pain
– does anything make it better or worse
- What treatments has this responded to
- can you rate the pain on a scale of 0-10
- How are you generally – are you fit and well

Then go into more specific questions about symptoms:
- What were you doing before the blackout, can you remember what happened during the blackout and what happened after the blackout
- in what position was the patient - lying, standing, seated
- where you sleep deprived or have drunk a lot o alcohol
- have you had any recurrent episodes and what were you doing when it happened
- in the case of vertigo - is there recurrence on turn gin the head or sitting up from lying flat - indicate benign positional vertigo
- availability of thrombolysis for stroke means that the time of onset of symptoms need to be noted
- what are triggering factors
- patterns of episodes over time

Ideas Concerns Expectations
- Do you have any idea of what might be going on
- Is there anything that is worrying you specifically
- What were you hoping id be able to do for you today


Past Medical history
- Do you have any medical conditions
- Have you seen anyone for this before
Specific questions
- Have you had contact with those that are unwell recently
-

Drug history and allergies
- What prescribed medication do you take
- What over the counter medication do you take
- Have you taken any illicit substances?
- Do you have any allergies?

Social history
- What do you do for a living
- Do you smoke – how long have you smoked, how many cigarettes do you smoke a day
- Do you drink
- Where do you currently live
- Do you have a support network that helps you
- Do you require any assistane in day to day life
- How much exercise do you do – how often and what type


Family History
- Has your family had any significant illness
- Are they well and still alive
Systematic review
Now just before we finish I just have some quick general questions to ask
- Have you had a fever
- Any weight changes
- Do you fill fatigued
- Have you had a cough?
- Do you get any stomach pain or nausea and vomiting
- Are you going to the toilet as usually?
- Have you had a headache, any visual changes, or motor and sensory disturbances
- Any chest wall pain, or trauma
- Do you have any rashes or other skin problems

Before I examine you is there anything else that you would like to add or think that I have missed

2

what should you seek to answer in a neurological history examination

- which part of the nervous system is affected and where is the lesion
- is it a single lesion or is there multiple lesion
- what is the underlying pathological process
- is this a purely neurological problem or a neurological manifestation of a systemic disease

3

what other history is good to have

- a collateral history from a caretaker should be sought
- but permission should be asked before hand

4

why is hardness important to know

- almost all right handed individuals and at least 3/4 of left handed ones are left hemisphere dominant for language
- this information is important when localising al lesion

5

the more left handed the patient the more likely they are to be ...

- the more left handed the patient is the more likely they are to be right hemisphere dominan

6

why should you look at levels of severity

- MS - patterns and symptoms are important in determining the nature of the disease - e.g. primary progressive, relapsing remitting or secondary progressive

7

what suggests cortical pathology

- epileptic seizures
- disturbances of consciousness
- cognitive and psychiatric symptoms (e.g. dementia)
- organic psychoses
- hemiparesis
- hemisensory disturbance
- visual field deficits (homonymous hemianopia).

8

What are the pathological processes that commonly affect the cortex

- vascular disease
- tumour
- abscess
- trauma
- atrophy/infection of the temporal lobe

9

what are frontal lobes important for

- important for planning and executive function

10

what happens if there is damage to the frontal lobe

- may be disinhibited or flippant
- check there attention span - ask them to recall a string of numbers
- be ware that they may lack capacity and need a moral assessment of their ability to consent for investigation and treatment
- changes in personality, mood, insight and urinary incontinence

11

what happens if there is a lesion to the parietal lobe

- can be difficult to identify
- loss of function such as temperature or proprioception suggests a lesions low down the chain
- disorders such as agnosia and apraxia or inattention suggest cortical pathology

12

what happens if there is a lesion to the temporal lobe

- speech and language is affected if the left/dominant temporal lobe is involved
- memory (particularly episodic memory) is affected
- the hippocampus and temporal lobe are needed to form new memories and are sensitive to anoxia
- seizures that begin in the temporal lobe may be preceded by a sense of deja vu or a strange smell
- medial temporal lobe is commonly involved in viral encephalitis and acute temporal lobe symptoms associated with headache in young patients should suggest this diagnosis

13

How do you know of damage to the occipital lobe

- visual deficits
- scotoma
- ask western symtpoms are bilateral and in particular ask if there is any history of trauma - after sudden deceleration injury
- contra-coup injury may damage both occipital poles simultaneously

14

what is a scotoma

a scotoma is when there is a black spot in the visual field where the macula which is rich in photoreceptors is located

15

list some extrapyramidal disease characteristics

- parkinsons - stiffness and slow movement
- hypokientic syndromes due to lesions in the palladium or substantially nigra
- tremor
- putamen and caudate lesions can lead to hyperkinetic disorders in which tone tends to decrease
- sub thalamic damage - ballismus - more violent and less smooth involuntary movement

16

what does a transection of the cord in the cervical spine result in

- spastic paralysis of all four limbs (tetraplegia)

17

what does a transection in the thoracic or lumbar spine affect

- just the lower limbs - paraplegia

18

what indicates damage to the conus and caudal equine

involvement of the perineum with or without associated autonomic dysfunction (such as urinary retention) may indicate pathology in the conus or cauda equina

19

is brown sequard unilateral or bilateral

unilateral

20

what are the causes of brown sequard

trauma, vascular insult and tumour compression

21

what happens when you have an anterior cord infarction due to spinal artery occlusion

- symptoms may spare the posterior columns - so you will still have touch, vibration and proprioception

22

what is extrinsic compression suggested by

- neck or back pain
- malignancy may have metastasised to the vertebrae and recent procedures such as epidural anaesthesia or facet injection

23

what do peripheral nerve lesions give rise to

- weakness, wasting and sensory disturbances
- causes symptoms such as tingling and dysaesthesia or negative symptoms such as numbness or lack of sensation
- symmetrical polyneuropathy affects the feet more than the hands because the nerves are longer

24

what is myopathy

Muscle disease is a purely motor condition (without sensory symptoms), as is motor neurone disease.

- important to enquire about drug history as corticosteroids or statins may be implicated

25

where does proximal myopathy commonly present

- presents with difficulty climbing the stairs, rising from a allow chair or reaching up for things on a high shelf

26

what does myasthenia gravis do

Myasthenia gravis causes fatigability with increased weakness after activity or later in the day.

27

what suggests an inflammatory myopathy

- pain and tenderness of the muscles may suggest an inflammatory myopathy

28

what are the commonly prescribed drugs that may cause peripheral neuropathy

- Amiodarone
- Amitriptyline
- Dapsone
- Disulfiram
- Gold
- Hydralazine
- Isoniazid
- Lithium
- Metronidazole
- Nitrofurantoin
- Phenytoin
- Pyridoxine
- Reverse transcriptase inhibitors (as part of antiretroviral
therapy)
- Thalidomide
- Vinblastine
- Vincristine

29

what other questions should you ask in a history

- are bladder, bowel and sexual function normal - autonomic nervous system
-infections - sepsis, sore throat, myocarditis
- rash or joint problems - vasculitis
- cardiac symptoms are important when diagnosing loss of consciousness
- sleep disturbance may indicate a brainstem lesions
- features of malignancy
- close with are there any other relevant symptoms that you wish to disclose

30

Describe how to do a cranial nerve examination

WIPER
- wash your hands
- introduce yourself
- permission and check if they are in pain
- expose the patient
- reposition the patient

ask whether they are right or left handed
- hand dominance signals cerebral hemisphere dominance

test for aphasia
receptive
- puff out the cheeks
- close and open the eyes
expressive
- ask them what a cup is
- and list common objects

Test dysarthria
- ask them to say something such as prince regent street

mental state
- perform a simple knowledge test
- perform a simple memory test


Cranial nerve examination
1. olfactory nerve - ask them to smell something common with there eyes closed

2. optic - get them to read something - small print at near vision and large print at a distance
- test pupil reflex reaction - test one eye at the time
- use an ophthalmoscope to look at the fundus
- assess the visual fields - use the bunny hands

3. oculomotor, trochlear, and abducens
- test for eye movement - H sign and get them to follow
- hand on their chin
- observe for nystagmus
test accommodation - look at a distance and then focus on the finger as you bring it in

4. trieminal nerve - has both motor and sensory function
Sensation
- touch over the three divisions of the nerve - ophthalmic, maxillary and mandibular

motor
- clench there jaw why you feel over the master muscle
- test jaw jerk with the patella hammer
- test the corneal reflex is present

7, facial nerve
- get them to tightly close there eyes and see whether the eyes can be open
- ask them to frown
- ask them to blow out there cheeks

8, auditory nerve
- test the hearing initially by whispering into each ear
- then find if it is due to conductive or perceptive deafness
- rinnes test - differentiates between nerve perception and air conduction deafness - placed on mastoid
- webers test - nerve perception and air conduction deafness - placed on centre of the forehead

9 and 10. glossopharyngeal and vagus never
- uvula is central
- test gag reflex

11. accessory nerve
- SCM and trapezius
- ask them to shrug there shoulders and push down
- push hand away with the jaw

12. hypoglossal
- look for washing and abnormal movements of the tongue
- look for tongue deviation