clinical examination nervous system
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Clinical examination of the Nervous System
DrPuneet Kaur
Schemata
Examination OfHigher FunctionsCranial nervesMotor system(incl reflexes)Sensory systemAutonomic nervous system
Examination of Higher Functions
Mental stateMemory Speech
Two cerebral Hemisphere:1.Dominant or Cerebral Hemisphere-categorization and symbolization2.Representational Hemisphere-spatiotemporal relations
Hemisphere specialisation related to handedness
Mental state
Appearance and BehaviorEmotional stateDelusions and HallucinationOrientation in Place and TimeLevel Of ConsciousnessIntelligence
Appearance and Behaviour
DressPersonal HygieneGeneral GroomingFacial ticsVerbal or physical aggression
Emotional state
Mood : facial expression (reflective of depression, mania, anxiety, schizophrenia)
Sleep and dreams : insomnia , sleep disturbing dreams
Delusions and Hallucinations
Delusion : false and unshakeable beliefs which continue to be held despite evidence to contrary.Hallucination : False impressions referring to organs of special sense(hearing , smell , vision etc) for which no cause can be found.
Orientation In Place and Time
Disorientation : Organic Brain DiseaseSchizophrenicsHysterical states
Level of Consciousness
Stupor-Patient shows some response, example to painful stimuli
Coma-makes no psychologically meaningful response to external stimulus or to internal need
Intelligence
Approximate from occupation and educational qualifications
Formal testing: calculating ability , serial subtraction, copying a complex figure etc
Memory
Recent or short term memoryRemote or long term memory
Retrograde amnesia for events immediately before brain concussion
Language or Speech
Aphasias
Dysarthria
Aphasia
Sensory or Fluent aphasiaLesion in Wernicke area-area 22,sensory speech centre(Posterior end of the superior temporal gyrus in the dominant hemisphere)Symptoms:-speech not disturbed but the person talks excessively that makes little sense-Pure word blindness or anomic aphasia
Motor or non fluent aphasiaLesion in the Broca’s area-area 44,motor speech centre(inferior frontal gyrus of dominant hemisphere)Symptoms:-Loss of articulate speech or inability to write or both-person is dumb and speech is slow-words are hard to come by limited to 2-3 words
Global aphasia:result of loss of both Wernicke’s and Broca’s area
Dysarthria
There is difficulty in spoken speech.
Cranial Nerves
12 pairs of cranial nervesSome are afferent(sensory)Some are efferent(motor)Some are mixed nerves
First nerve : Olfactory nerve
Origin : From the olfactory epithelium
Function: Pure sensory nerve concerned with olfaction (smell)
Paralysis:-AnosmiaTest:-Clove oil presented to each nostril separately
Anosmia : complete absence of smell
Parosmia : is alteration in the character of smell
Hypoosmia :reduction in the sense of smell
Second Nerve : Optic Nerve
Origin :From the Retina
Function: Pure sensory nerve-transmission of visual sensations to brain
Test-Visual acuity -Field of vision -Color vision -Examination of fundus(Opthalmoscopy)
Visual acuity
Near vision: Jaeger’s chartDistant vision: Snellen’s chart
Factors affecting visual acuity
Optical: state of image forming mechanism of eye
Retinal factors: acuity maximal at the fovea centralis
Stimulus factors : size of object and distance from eye,color of object
Field of vision
Confrontation testsPerimetryRed pin test
Color vision
Yarn (spun thread) matching test or Holmgreins skeins of colored wool test
Ishihara chartsEdridge green lantern
Third(Oculomotor)Fourth(trochlear)Sixth(Abducent)nerves
Origin: from a series of nuclei which begins in the floor of the sylvian aqueduct extending upto the fourth ventricle
Function: Mixed nerves-innervate the eye muscles and bring sensation from proprioceptors in eye muscles
Test1.Look for ptosis ,squint,nystagmus2.Test for ocular movement3.Examination of Pupil
Fifth nerve: Trigeminal nerve
Origin : From the lateral surface of Pons at about its middle
Function: It is a mixed nerve with sensory, motor and secreto-motor components
3divisions-Opthalmic -Maxillary - Mandibular
Effect of Paralysis of 5th nerve
Opthalmic division-loss of cut. sensation
-loss of corneal reflex Maxillary division-loss of palatal
reflex -loss of cut.sensation Mandibular division-loss of sensation -weakness of muscles of mastication
Test for sensory function
Touch, pain,pressure,temperature over the face
Corneal reflex-Touch the cornea with a wisp of cotton-subject blinks
Test for motor function : Muscles of mastication
Clench teeth-masseter and temporalis stand out with equal prominence on each side
Open mouth : jaw will deviate to paralysed side-pushed by healthy external pterygoid
Seventh Nerve-Facial
Origin: From the Pons , lateral to that of the sixth nerve nucleus
Function:Mixed nerveMotor fibre-all the muscle of face and scalp except levator palpebrae superiorisStylohyoidBuccinatorStapedius muscle
Sensory fibres-taste sensation from ant. 2/3 of tongueSecreto-motor fibres-supplies lacrimal gland , sublingual and submandibular salivary gland(all salivary gland except the parotid gland)
Effect of paralysis of 7th nerve
Loss of facial expression Furrows over forehead smoothen out Hyperacusis Loss of taste-ant 2/3 of tongue Xeropthalmia,decreased salivation
Tests for 7th nerve
Smile or show upper teeth Close his eyes against resistance Whistle Inflation of cheeks Loudness of sound Taste :ant 2/3 Schirmer’s test for lacrimation
8th nerve: Auditory or vestibulocochlear
Origin : From the groove in between the junction of Pons and Medulla.
Function:Pure sensory nerve supplying the
Vestibular and cochlear portion of ear
Effect of Paralysis of 8th nerve
VertigoNystagmusLossof hearing
Tests for vestibular function
Romberg’s signStand with feet together and close his eyesBarany’s caloric testWater at 7 degree celsius above and below normal body temperature
Cochlear function : Hearing tests
Watch test Tuning fork test : Rinne’s , Weber’s , Schwabach Audiometry
9th nerve:Glossopharyngeal Origin:5-6 rootlets to upper part of
medulla oblongata Function : Mixed nerveMotor fibres supply stylopharyngeus msSensory fibre to posterior 1/3 portion of tongueAnd mucus membrane of pharynxSecretomotor fibres supply the parotid gland
9th nerve paralysis
Loss of taste from post. 1/3 of tongue
Decreased salivary secretion
Test of 9th nerve
Taste sensation in Post. 1/3 of tongue
Palatal reflex
10th nerve: Vagus
Origin:Attached by 8-10 rootlets to the lateral aspect of medulla oblongata below the origin of 9th nerve
Function: mixed nerveMotor to involuntary ms of respiration,heart and part of GIT & voluntary ms of pharynx, larynx and soft palateSensory to GIT upto right 2/3 of colon &mucus memb. of pharynx, larynx and soft palate.
Paralysis of 10th nerve
Regurgitation of fluids through nose
Nasal tone in voiceHoarse and deep voice
Test for 10th nerve
Soft palate movement Laryngoscopy
11th nerve:accessory
Origin :Cranial part and spinal part
Function: Pure motor nerveSupplies Sternocleidomastoid and Trapezius
Test Of 11th nerve
Move the headShrug shoulder
12th nerve: Hypoglossal
Origin: From lowermost part of medulla oblongata
Function :Pure motor nerveSupplies all Ms of tongue.
Paralysis of 12th nerve
Defective articulation Deviation of tongue
Test of 12th nerve
Tongue protrusion-deviation