neurological examination, med stud 3

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Neurological Examination

Surat Tanprawate, MD, MSc(Lond.), FRCPTDivision of Neurology, Chaing Mai University

Thursday, December 15, 2011

Brain function

Thursday, December 15, 2011

Brain function

Thursday, December 15, 2011

Neurological skill• Chief complaint

• History taking

• Neurological examination

• screening neurological examination

• focused neurological examination

• Consequence of the exam

• Skill and method

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Aim of neurological exam

• To localized the lesion

• Central vs Peripheral nervous system

• symmetrical vs asymmetrical

• If central: cerebrum, midbrain, spinal cord

• If peripheral, is it: nerve, muscle, NMJ

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Equipment• Penlight

• Tongue blade

• Tuning fork

• Familiar objects(coin, key, paper clip)

• Cotton wisp

• Reflex hammer

• Aromatic substances

• Test tubes of hot and cold water

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Consequence of Neurologic Exam

• Mental status

• Consciousness: Level of consciousness, orientation

• Higher cortical function

• Cranial nerves

• Motor system

• Reflex

• Sensory

• Coordination

• Gait and balance Special testThursday, December 15, 2011

Consciousness

Ascending Reticular Activating System(ARAS): level of consciousness: wakefulness: stimuli and response: Glasglow Coma Score(GCS)

Higher cortical function: content of consciousness: awareness: orientation; time, place, person: higher cortical function: Mini-mental state examination

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Level of consciousness

• Wakefulness

• Drowsiness

• Semi-coma

• Coma

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Glasglow Coma Score (GCS)

• Eye response

• Verbal response

• Motor response First published in 1974 by Graham Teasdale and Bryan J. Jennett,

Professor of neurosurgeryUniversity of Glascow

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Glasglow Coma Score (GCS)

1. No eye opening

2. Eye opening in response to pain (Patient fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)

3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.)

4. Eyes opening spontaneously

E

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Glasglow Coma Score (GCS)

1. No verbal response

2. Incomprehensible sounds. (Moaning but no words.)

3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)

4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)

5. Oriented (Patient responds coherently and appropriately to questions such as the patientʼs name and age, where they are and why, the year, month, etc.)

V

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Glasglow Coma Score (GCS)

1. No motor response

2. Extension to pain (abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate posture)

3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate posture)

4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)

5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)

6. Obeys commands. (The patient does simple things as asked.)

M

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Consciousness

• Impairment of self awareness, person, environment, time

• Clouding of consciousness

• Confusional state

• acute(delirium), chronic(severe dementia)

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ConsciousnessLevel(arousal) and content(awareness) of

consciousness

Arousal and awareness, the two components of consciousness in coma, vegetative state, minimally conscious state, and locked-in syndrome.

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Higher Cortical Function

• Memory

• Language

• Calculation

• Higher motor function(Praxis)

• Higher sensory function(Gnosis)

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Memory

• Short term memory

• ถามคําให้ทวน 3 คํา “ต้นไม้ รถยนต์ มือ”

• Long term memory

• ชื่อประเทศ ชื่อพ่อแม่

Thursday, December 15, 2011

Language• Fluency: ความคล่องของการพูด

• Comprehension: 1 step, 2 step, 3 step

• Repetition “ยายพาหลาน ไปซื้อขนมที่ตลาด”

• Naming: ปากกา นาฬิกา แก้วน้ํา

• Reading

• Writing

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Aphasia• Aphasia refers to an impairment in

linguistic communication produced by brain dysfunction

• It must be distinguished from other disorders of verbal output such as dysarthria, mutism, and the abnormal language production of patients with thought disorder

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A: Wernicke's areaB: concept centerM: Broca's area

a--> A-auditory input to Wernicke's areaM --> m-motor output from Broca's areaA --> M-tract connecting Wernicke's and Broca's areasA --> B-pathway essential for understanding spoken inputB --> M-pathway essential for meaningful verbal output.

Lichtheim's diagram of the language system

Conduction aphasia

Transcorticalsensory aphasia

transcortical motor aphasia

Pureword deafness

Articulatory disorder (aphemia)

Sensory aphasia

Motor aphasia

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Praxis

Gnosis

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Mini-Mental State

Examination (MMSE)

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Cranial nerve

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Olfactory nerve (CN I)

• Test each nose with familiar non-irritate smell

• Coffee bean

Thursday, December 15, 2011

Optic nerve (CN II)

• Visual acuity

• Visual field

• Fundoscopy

• Swinging flashlight test

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Visual acuity

• Using hand held card (14 inches) or snellen wall chart, assess each eye separately

• Direct patient to read aloud line with smallest lettering that theyʼre able to see

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Visual acuity: Assessment

• 20/20 = patient can read at 20` with same accuracy as person with normal vision.

• 20/400 = patient can read at 20` what normal person can read from 400` (i.e. very poor acuity).

Thursday, December 15, 2011

Visual field

Thursday, December 15, 2011

Pupillary response

Direct light reflex

Consensual light reflex

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Fundoscopic examination

Thursday, December 15, 2011

Cranial nerve III, IV, VIExtraocular movement

Thursday, December 15, 2011

Thursday, December 15, 2011

Trigeminal nerve (CN V)

• Facial sensation

• Motor: jaw strength and muscle bulk

• Corneal reflex

Thursday, December 15, 2011

Masseter test

Thursday, December 15, 2011

Corneal Reflex

Thursday, December 15, 2011

Facial nerve (CN VII)

“Tear, Ear, Taste, Face”

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Thursday, December 15, 2011

Thursday, December 15, 2011

Vestibulocochlear nerve (CN VIII)

Rinne test

Weber test

Thursday, December 15, 2011

A normal soft palate is illustrated on the left. On the right, a right palatal palsy from a lower motor neuron X nerve lesion has resulted in deviation of the uvula to the left.

Vagus nerve (CN X)

Hypoglossus nerve (CN XII)

Thursday, December 15, 2011

Motor examination

• Muscle bulk

• Muscle fasciculation/cramp

• Muscle tone

• Muscle strength

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Thursday, December 15, 2011

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Reflex

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ReflexSuperficial Reflexes

• Plantar reflex• Stroke lateral side of foot from heel to the ball, then across to the medial side• Normal response is a positive plantar

reflex• Plantar flexion of all toes

• Abnormal response is the Babinski sign in those 2 yoa• Dorsiflexion of the great toe with or

without fanning of the other toes

Thursday, December 15, 2011

Sensory function

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Sensory function• Primary sensory functions

• Always with the personʼs eyes closed

• Sites

• Vision, hearing, smell, taste, and facial sensation• Hands• Lower arms• Abdomen• Feet• Lower legs

Thursday, December 15, 2011

Sensory function• Primary sensory functions

• Superficial touch

• Use a cotton wisp

• Have the person point to the area touched

• Superficial pain

• Sharp and dull sensations

• Allow 2 seconds between each stimulus

• Temperature and deep pressure

• ONLY USED when superficial pain sensation is not intact

Thursday, December 15, 2011

Sensory function• Primary Sensory Functions

• Vibration• Place stem of tuning fork against bony prominences

• Begin distally

• Sites

• Sternum

• Finger – wrist – elbow - shoulder

• Toes – ankle – shin

• Position of joints (great toes, one finger on each hand)• Up

• Down

Thursday, December 15, 2011

Proprioception• Proprioception

• The sensation of position and muscular activity originating from within the body which provides awareness of posture, movement, and changes in equilibrium

• Test

• Joint position test

• Rombergʼs test

Thursday, December 15, 2011

Sensory function• Cortical Sensory Functions

• Always with the personʼs eyes closed

• Stereognosis

• Ability to identify a familiar object by touch and manipulation

• Tactile agnosia: inability to recognize objects

• Graphesthesia

• With a blunt pen, draw a letter or number on the palm

• Should be readily recognized

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Sensory function• Cortical Sensory Functions

• Point location

• Touch an area of the body and ask the person to point to where you have touched

• This is being tested the same time as superficial touch

• Extinction phenomenon

• Simultaneously touch one or both sides of the body

• Ask the person to point to where you have touched

Thursday, December 15, 2011

Sensory function• Cortical sensory functions

• Two-point discrimination

• Use two pointed objects, alternate touching skin with one or two points

• Find the distance at which the person can no longer discriminate 2 point

• Finger tip 2-8 mm• Toes 3-8 mm• Palms 8-12 mm• Forearms 40 mm• Upper arms and thighs 75 mm

Thursday, December 15, 2011

Cerebellar function• Coordination and fine motor skill

• Rapid rhythmic alternating movement

• Have seated person alternately pronate and supinate hands, patting knees, and gradually increasing speed OR

• Have person touch thumb to each finger on the same hand sequentially from index to little finger and back, gradually increasing speed

• person should be able to do these movements smoothly, maintaining rhythm, with increasing speed

• Observe for slow, stiff, non-rhythmic, or jerky movements

Thursday, December 15, 2011

Cerebellar function

• Coordination and fine motor skill• Accuracy of movement

• Finger-to-finger test with personʼs eyes open

• Movements should be rapid, smooth, and accurate

• Consistent past pointing may indicate cerebellar impairment

• Heel-to-shin with person supine

• Should move heel from knee up and down the shin in a straight line, without irregular deviations to the side

Thursday, December 15, 2011

Finger-to-nose test. A. Normal: Smooth trajectory throughout movement. B. Cerebellar hemisphere dysfunction: Tremor increases in amplitude as finger approaches target. C. Parkinsonian: Tremor may be present at initiation of movement, but smoothes out as finger approaches target. D. Essential tremor: Low-amplitude fast tremor throughout trajectory, may worsen as finger approaches target.

Thursday, December 15, 2011

Cerebellar function

• Stance and gait

• Gait

• Tamdem walk

• Rombergʼs test

Thursday, December 15, 2011

Consequence of Neurologic Exam

• Mental status

• Consciousness: Level of consciousness, orientation

• Higher cortical function

• Cranial nerves

• Motor system

• Reflex

• Sensory

• Coordination

• Gait and balance Special testThursday, December 15, 2011

Thank You for Your Kind Attention

Surat Tanprawate, MD, MSc(Lond.), FRCP(T)CertHE(Hist Med)Neurology staff,

Division of Neurology, CMUThe Northern Neuroscience Center, CMU

Downloadable at www.openneurons.com

Thursday, December 15, 2011

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