-
4 regions of the brain
- cerebrum
- diencephalon
- BS
- cerebellum
-
Aggregations of neuronal cell bodies
GM
-
Neuronal axons coated w/meylin
WM
-
Allows nerve impulses to travel more rapidly
myelin sheaths
-
What structures are located in the diencephalon
-
processes sensory impulses & relays to cerebral cortex
thalamus
-
maintains homeostasis & regulates temp, HR, BP
hypothalamus
-
affects endocrine system & governs emotional behaviors
hypothalamus
-
hormones secreted in hypoth act on what
pituitary gland
-
coordinates all movement & helps maintain body upright in space
cerebellum
-
spinal cord extends from what to what
BS to L1-L2
-
motor & sensory pathways enter/exit spinal cord via what
- anterior=motor
- posterior=sensory
- spinal & peripheral nerves
-
Spinal cord is divided into 5 segments name them
- C1-C8
- T1-T12
- L1-L5
- S1-S5
- coccygeal
-
which CN's arise from the diencephalon & brainstem
3-12
-
How many pairs of peripheral nerves are there
-
anterior or ventral root contains what type of fibers
motor
-
posterior or dorsal root contains what type of fibers
sensory
-
these nerve cell bodies lie in the motor strip of cerebral cortex & in BS nuclei; with axons synapsing w/motor nuclei
upper motor neurons
-
These have cell bodies in spinal cord termed ant horn cells in which their axons transmit impulses through the ant roots & spinal nerves into peripheral nerves that terminate at the NMJ
lower motor neurons
-
this tract mediates vol movement & integrates skilled, complicated, delicate movements by stimulating selected muscular actions while inhibiting others
corticospinal tract (pyramidal)
-
which tract inhibits muscle tone
CST/pyramidal
-
where does the corticospinal tract orginate
motor cortex
-
where does the corticospinal tract fibers cross & explain their route
lower medulla & continue down & synapse w/ant horn cells or intermediate neurons
-
Tracts synapsing in BS w/motor nuclei of CN's are termed
corticobulbar
-
which system helps to maintain musc tone & control body movements such as gross automatic movements such as walking
basal ganglia sys
-
which system receives both sensory & motor input & coordinates motor activity; maintains EQ & helps to control posture
cerebellar sys
-
what kind of motor pathways impinge on the ant horn cells
-
what happens when UMN systems are damaged above the crossover of its tracts in the medulla
you will have motor impairment to the contralateral side
-
what happens when UMN systems are damaged below the crossover of its tracts in the medulla
you will have motor impairment to the ipsilater side
-
this type of lesion produces increased musc tone & deep tendon reflexes are exaggerated
UMN lesions
-
does disease to the BGS or CS produce paralysis
no but can be disabling
-
Damage to this sys will produce an increase in musc tone, disturbances in posture & gait or bradykinesia
BGS
-
What is a slowness or lack of spontaneous & automatice movements termed
bradykinesia
-
damage to this area impairs coordination, gait, EQ & decreases musc tone
cerebellar
-
what do sensory impulses participate in
- reflex
- conscious sensation
- calibrate body pos in space
- regulate internal autonomic fx:BP HR Resp
-
how do the sensory fibers that register sensations such as temp, position, touch pass through what
peripheral nerves & post roots where they enter the SC. Once there the sensory impulse reaches either the spinothalamic tracts or post columns
-
where do the fibers conducting pain & temp sensations pass into
post horn of SC & synapse w/2nd sens neurons
-
where do the fibers conducting crude touch pass through
post horn & synapse w/ 2nd neurons
-
where do the fibers that elicit pain, temp, crude touch cross into after synapsing w/2nd neurons
cross over into & upward to the spinothalamic tract into the thalamus
-
these fibers that conduct sensations pass directly into post columns of the cord & travel upward to medulla together w/fibers transmitting fine touch & synapse in the medulla w/2nd sens neurons
position & vibration
-
at what level is the general quality of sensation is perceived as pain, pleasant, unpleasant or cold
thalamic level
-
where are full perceptions of sens impulses from the thalamus conducted to
sens cortex where higher order discriminations are made
-
A lesion in sensory cortex may not impair perception pain, touch, position but may impair what
finer discrimination
-
Band of skin innervated by the sensory root of a single spinal nerve
dermatome
-
involuntary stereotypical response that may involve 2 neurons across a single synapse
reflex
-
the deep tendon reflex in the arms & legs in what type of reflex
monosynaptic that illustrates the simplest unit of sens & mot fx
-
when are reflexes termed polysynaptic
when they involve interneurons btwn sens & mot neurons
-
what must be intact for the reflex to fire
- sens nerve fib
- SP synapse
- MN fib
- NMJ
- musc fib
-
when does the musc suddenly contract in a reflex arc
when impulse crosses the NMJ
-
what are the deep tendon reflexes
- Biceps-c5 & c6
- tri-c6 & c7
- Brachiorad-c5 & c6
- knee-l2,l3,l4
- ankle=s1
-
what are the cutaneous stimulation reflexes
- plantar resp=L5 & S1
- anal reflex=S2,S3,S4
- Abdominal=upper=T8,9,10
- Lower=T10,11,12
-
what are the common or concerning symptoms of the NS
- headache
- dizzy or vertigo
- general, proximal, distal weakness
- numbness
- abnormal or loss of sensations
- loss of consciousness, syncope, near syncope
- seizures
- tremors or inv movements
-
what are the 2 most common symp in neurologic disorders
-
worst headache of life may indicate
sub A hem
-
difficulty forming words
dysarthria
-
difficulty with gait or balance
ataxia
-
peculiar sensations w/out obvious stimulus
paresthesias=arm goes to sleep
-
distorted sensations in response to stimulus & may last longer than stimulus itself
dysethesias
-
vertebrobasilar TIA can result in what
- diplopia
- dysarthria
- ataxia
- weak or paralysis
-
Focal weakness may arise from what type of lesions in the CNS
- ischemic
- vascular
- mass lesions
-
Bilateral predominantly distal weakness in what
polyneuropathy
-
What is it when weakness is made worse w/repeated effort & improved w/rest suggests
myastenia gravis
-
burning pain in painful sensory what
neuropathy
-
Sudden but temp loss of consciousness & postural tone that occurs w/decreased blood flow to the brain refered to as fainting
syncope
-
A paroxysmal disorder caused by sudden excessive electrical discharge in the cerebral cortex
seizure
-
What are some areas of health promotion & counseling in regards to the NS
- preventing stroke or TIA
- reducing risk of peripheralneurophathy
- detecting 3 D's=delirium; dementia & depression
-
A sudden neurological deficit caused by CVI or hemorrhage
stroke
-
This type of stroke may be intracerebral or subarachnoid
hemorrhagic
-
this type of stroke is a sudden focal neurologic deficit defined as lasting less than 24hrs but typically less than an hour
TIA
-
After a TIA when is the risk of a stroke the highest
first 30 days after TIA
-
What is the most common cause of an ischemic symptoms & signs
occlusions of MCA which can cause visual field cuts & contralateral hemiparesis & sensory deficits
-
In the left hemisphere occlusion of MCA will produce what
aphasia
-
In the Right hemisphere occlusion of MCA will produce what
- neglect
- inattention
- to opposite side
-
what are some warning sign of a stroke
sudden numbness, confusion, trouble speaking & walking & severe headache
-
Risk factors for stroke
- hypertension
- smoking
- hyperlipidemia
- diabetes
- heavy alcohol use
-
what is key for preventing a hemorrhagic stroke from a intracerebral hemorrhage
controlling hypertension
-
What is the most common cause of peripheral neuropathy
diabetes
-
Diabetes causes several types of neuropathy including
- distal symmetric sensorimotor polyneurophathy
- autonomic dysfunction
-
What is the most common of the diabetic neuropathies
autonomic dysfunction leading to ED, orthostatic hypotension, gastroparesis
-
what causes patchy sensory & motor deficits in at least 2 separate nerve areas
neuritis multiplex
-
What causes thigh pain & proximal lower extremity weakness that is initially unilateral
diabetic amyotrophy
-
how to test CN I
occlude each nostril & test different smells
-
how to test CN II
- Visual acuity
- inspect fundi
- Vis fileds by Confr
-
how to test cn II,III
- inspect pupil size & shape
- Light & near response
-
hot to test cn III, IV, VI
- EOM's in 6 cardinal directions
- lid elevation & convergence
-
how to test cn V
- palpate temporal, masseter musc
- clench teeth
- forehead, cheek, jaw=sharp,dull sensation
- may need to test corn reflex
-
how to test cn vii
- face=asymmetry
- tics & abnormal movements
- rais eyebrows
- frown
- close eyes tightly
- show upper teeth
- smile
- puff cheeks
-
hot to test cn viii
- hearing=lateralization
- AC vs BC
-
how to test ix & x
- voice is hoarse
- swallowing
- inspect movement of palate=ah
- Gag reflex if needed (warn patient)
-
how to test xi
- patient shrug shoulders=resistance
- contraction of SCM against resistance
-
how to test xii
- protrude tonge & move it side to side
- assess for symmetry & atrophy
-
you could see disc pallor in what
optic atrophy
-
you could see disc bulging in what
papilledema
-
Difference in pupil size or shape
aniscoria
-
involuntary jerking movement of eyes w/quick & slow components
nystagmus
-
What should you look for when examining the motor system initially
- position
- movement=tremors, tics, fasciculations
- muscle bulk
- tone
- presence of atrophy
-
what nerves are possibly involved when there is localized atrophy of the thenar & hypothenar eminences
- median damage
- ulnar damage
-
Fasciculations w/atrophy & musc weakness suggest disease of what motor unit
peripheral
-
marked floppiness indicates what
musc hypotonia or flaccidity
-
Increased resistance that worsens at the extremes of range
spasticity & is often seen in corticospinal tract disease
-
Increased resistant throughout ROM & in both directions that is not rate-dependent
rigidity
-
Impaired strength is called weakeness or what
paresis
-
Absence of strength is called what
paralysis or plegia
-
Weakness of 1/2 of the body
hemiparesis
-
paralysis of 1/2 of the body
hemiplegia
-
paralysis of legs
paraplegia
-
paralysis of all four limbs
quadriplegia
-
inability to form the OK sign normally with the thumb & index finger pinched together; weakened pronation
Ant interosseous
-
Thenar eminience wasting;sensory loss to thumb,index finger, mid finger;benediction hand
median
-
inability to extend the wrist(wristdrop) w/out sensory loss to the dorsum of hand
post interosseous
-
Wristdrop w/sensory loss to dorsum of the hand
radial
-
Clawhand; motor deficits of intrinsic musc of hand; first dorsal interosseous wasting; hypothenar eminence wasting
ulnar
-
how is muscle strenght graded
0 to 5 scale
-
what does 0 represent on the musc str scale
no musc contr detected
-
what does 1 represent on the musc str scale
barely detectable flicker or trace of contr
-
what does 2 represent on the musc str scale
active movement of the body part w/gravity eliminated
-
what does 3 represent on the musc str scale
active movement against gravity
-
what does 4 represent on the musc str scale
active movement against gravity & some resistance
-
what does 5 represent on the musc str scale
active movement against full resistance w/out evident fatigue; this is normal musc str
-
what does weakness of extension in the wrist possibly caused by
- radial nerve damage
- CNS damage=hemiplegia (stroke or MS)
-
nerve root & nerve for bi flexion
c5 & c6 musculocutaneous n
-
nerve root & nerve for tri ext
c6 & c7 radial n
-
nerve root & nerve for wrist ext
c6 & c7 radial n
-
nerve root & nerve for hand grip
C7,8 T1 via median n
-
nerve root & nerve for finger abd
C8 & T1 ulnar n
-
nerve root & nerve for thumb opposition
C8 & T1 median n
-
nerve root & nerve for hip flexion
l2,3,4 femoral n
-
nerve root & nerve for hip ext
L4,5,S1,2 gluteal n
-
nerve root for hip abd
L4,L5,S1
-
nerve root for hip add
L2,3,4
-
nerve root for kn flexion
L4,5,S1, S2
-
nerve root for kn ext
L2,L3,L4
-
A weak grip in cervical radiculopathy could be a sign of what
- de quervain's tensosynovitis
- CTS
- arthritis
- EPI Condylitis
-
WEak finger abduction could be a disorder of what nerve
ulnar
-
Weak opposition of the thumb in what disorders affects what nerve
CTS=median
-
symmetric weakness of the proximal musc suggest what
myopathy
-
symmetric weakness of distal musc suggest what
polyneuropathy or peripheral nerve disorder
-
Testing for coordination test what important function
cerebellum
-
how should you test for coordination
- rapid alternating movements
- point to point movements
- heel down shin
-
unable to perform one movement quickly after the other in cerebellar disease is termed what
dysdiadochokinesis
-
Besides cerebellar disease what also can contribute to an impairment of rapid alternating movements
UMN weakness & BG disease
-
A gait that lacks coordination with reeling & instability is termed
ataxic
-
how to do you want to assess gait
- walk across room
- heel to toe
- on toes then on heels
- hop in place
-
when we test rapid alternating movements what part of the brain are we assessing
cerebellum function
-
when we test a patients ability to walk on toes & heals what part of the brain are we assessing
corticospinal tract
-
Coordination of muscle movement requires that four areas of the nervous system function in an integrated way. Coordinating eye, head, and body movements applies to which area of the nervous system?
Vestibular system
-
Difficulty w/hoping may be caused by what type of dysfunction
cerebellar
-
Which test is it when the patient stands w/feet together & eyes opn then closes eyes for 30-60 sec w/out support
romberg test
-
A positive romberg test could be caused by what
cerebellar ataxia
-
Patient stands for 20�30 seconds with both arms straight forward, palms up, and eyes closed; tap arms briskly downward
pronator drift
-
Pronation and downward drift of the arm is a positive test for what
pronator drift & caused by lesion in the corticospinal tract of the contralat hemisphere
-
what are the general principles for examining the sensory system
- compare both sides
- think dermatomes
- testing pain, temp, touch=compare distal & proximal
- map out boundaries
-
how should you test pain
use a disposable object such as a broken cotton swab or paper clip
-
how should you test light touch
cotton wisp
-
how should you test vibration
with a 128-Hz tuning fork on hand, DIP joint then big toe; compare both sides
-
how should you test proprioception
hold the big toe by its sides between your thumb and index finger, pull it away from the other toes, and move it up then down. Ask the patient to identify the direction of movement
-
place a key or familiar object in the patient�s hand and ask the patient to identify it (coin or other easy ID object)
stereognosis
-
outline a large number in the patient�s palm and ask the patient to identify the number (1 or 8)
graphesthesia
-
using two ends of an opened paper clip, or two pins, touch the finger pad in two places simultaneously; ask the patient to identify 1 touch or 2 (5mm is the standard)
2pt discrimination
-
lightly touch a point on the patient�s skin and ask the patient to point to that spot
point localization
-
touch an area on both sides of the body at the same time and ask if the patient feels 1 spot or 2
extinction
-
Inability to recognize numbers may suggest a lesion where
sensory cortex
-
what increases the distance btwn 2 recognizable pts
lesions of sens cortex
-
what are the gen principles for the examining of deep tendon reflexes
- proper wt hammer
- patient to relax
- hold hammer loosley
- strike tendon very brisk
- reinforcement
- grade=absent-brisk
-
What does 4+ describe on the reflex scale
clonus=very brisk hyperactive rhythmic oscillations btwn flex/ext
-
what does 3+ describe on the reflex scale
brisker than avg possibly but not necessarily of disease
-
what does 2+ describe on the reflex scale
avg;normal
-
what does 1+ describe on the reflex scale
somewhat diminished;low normal
-
what does 0 describe on the reflex scale
no response
-
hyperactive reflexes in the CNS lesions along desc corticospinal tract
hyperreflexia
-
hypoactive or absent reflexes in diseases of spinal nerve roots spinal nerves or peripheral nerves
hyporeflexia
-
which reflex is hypothyroidism often easily seen & felt
ankle
-
Sustained clonus indicates what type of disease
CNS disease
-
Bi reflex spinal root
c5,6
-
-
supinator or brachioradialis reflex sp root
c5,6
-
-
-
a hyperactive response required for assigning a reflex grade of 4, usually elicited at the ankle
clonus
-
what is considered the deep tendon reflexes
-
what is considered the cutaneous stim reflexes
- abdominal
- plant resp
- anal reflex
-
-
-
-
sudden brief nonrhythmic flex of hands & fingers indicates what
asterixis seen often in liver disease, uremia & hypercapnia
-
including the ABC�s (airway, breathing, circulation), level of consciousness (see table on next slide), pupillary response, ocular movements, and posture and muscle tone
assessment of stuporous or comatose patient
-
Dorsiflexion of big toe in plantar response signals what
Babinski response indicating CNS lesion of corticospinal tract
-
A marked babinski response is occasionally accompanied by what reflex response
flex of hip & knee
-
loss of anal reflex suggests a lesion in s2,3,4 reflex arc indicating what
cauda equina lesion
-
flexion of the hips & knees is a positive brudzinski's sign indicating what
possible menigeal inflammation
-
pain & increased resistance to extending the knee are positive kernig's sign that when bilateral could suggest what
menigeal irritation
-
what are the level of consciouseness arousal techniques & patient response
-
Speak to the patient in a normal tone of voice. An alert patient opens the eyes, looks at you, and responds fully and appropriately to stimuli (arousal intact).
alertness
-
Speak to the patient in a loud voice. For example, call the patient�s name or ask, �How are you?�
lethargy
-
Shake the patient gently, as if awakening a sleeper
obtundation
-
Apply a painful stimulus. For example, pinch a tendon, rub the sternum, or roll a pencil across a nail bed. (No stronger stimuli are needed.)
stupor
-
apply repeated painful stimuli
coma
-
A lethargic patient appears drowsy but opens the eyes and looks at you, responds to questions, and then falls asleep.
abnormal response to lethargy
-
An obtunded patient opens the eyes and looks at you, but responds slowly and is somewhat confused. Alertness and interest in the environment are decreased.
abnormal resp to obtundation
-
A stuporous patient arouses from sleep only after painful stimuli. Verbal responses are slow or even absent. The patient lapses into an unresponsive state when the stimulus ceases. There is minimal awareness of self or the environment.
abnormal resp to stupor
-
A comatose patient remains unarousable with eyes closed. There is no evident response to inner need or external stimuli.
abnormal resp to coma
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