hx & physical e xam in neurology. hx localization phenomenology hx etiology ph.e localization,...
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LOCALIZATION Cerebrum
Impaired intellect, memory, higher brain function Brain stem
unconsciousness LMN
paralysis with loss of DTRs muscle atrophy with fasciculation peripheral nerve or spinal root LMN + anesthesia
UMN involves whole muscle groups increased or spastic muscle tone +/- paralysis with DTR accentuation Positive Babinski
TERMINOLOGY
Paresis – slight or incomplete paralysis Paralysis (plegia) – loss or impairment
of motor function Hemiparesis Hemiplegia Paraplegia Quadriplegia
TERMINOLOGY
Atrophy – a decrease in size Hypertrophy
enlargement of an organ or part due to an increase in size of its constituent cells
Pseudohypertrophy increase in size without true hypertrophy
Spasticity – hypertonicity with increased DTRs Rigidity – stiffness or inflexibility Paratonia(gegenhalten) Flaccidity – loss of tone with diminished DTRs
MENTAL STATUS Alertness Attention Orientation
Person, Place, Time, & Situation Perception
Illusions = misinterpretations of real external stimuli Hallucinations = subjective sensory perceptions in the
absence of stimuli Judgment Memory
Immediate ,Short-term & long-term Speech
Information & vocabulary Common
Calculating Simple math Word problems
Abstract thinking Proverbs Similarities/differences
Construction Copy figures of increasing difficulty (i.e. circle, clock)
LEVELS OF CONSCIOUSNESS Alert and Oriented Letargic Obtunded
Drowsy/somnolent Clouded consciousness Slow thought, movement, and speech
Stuporous Marked reduction in mental and physical activity Vigorous stimuli needed to provoke a response
Comatose Completely unconscious Cannot be aroused by painful stimuli Absence of voluntary movement +/- reflexes
TESTING FOR APHASIAFluency Spontaneus speech
Word Comprehension
Comprehension of spoken language through recognition (“point to your nose”) or understanding (“Can dogs fly?”).
Repetition Repeat items of increasing complexity. Note the fluency and accuracy of the responses.
Naming Name a series of objects or colors. Gradually increase difficulty. Note the fluency and accuracy of the responses.
Reading Comprehension
Have the patient follow several simple written commands.
Writing Ask the patient to make up and write a sentence.
CRANIAL NERVES I - Olfactory II - Optic III - Oculomotor IV - Trochlear V - Trigeminal VI - Abducens VII - Facial VIII - Vestibulocochlear (Acoustic) IX - Glossopharyngeal X - Vagus XI - Accessory XII - Hypoglossal
CRANIAL NERVE I
Responsible for sense of smell Receptors located in the upper 1/3 of the
nasal septum. Test each nostril separately. Identify familiar odors. Avoid noxious substances
CRANIAL NERVE II Responsible for vision Test visual acuity!!!! Pupillary size
Swinging-flashlight test Visual fields
Peripheral vision Test by confrontation
Fundoscopic examination Papilledema
CRANIAL NERVES III, IV, VI
CN III involved in: Pupillary reflex Opening of the eyelids Most extraocular movements
CN IV provides downward/inward eye movement
CN VI provides lateral eye movement
CRANIAL NERVES III, IV, VI Check pupillary reaction/reflex
Direct & consensual Check eye movement through all six Cardinal
fields
Look for nystagmus
PUPIL ABNORMALITIES
Marcus-Gunn pupil results from reduced afferent input in the affected eye pupil fails to constrict fully rapidly stimulate each eye in succession and observe the
direct and consensual light response in each stimulation of the normal eye produces full constriction in
both pupils. immediate subsequent stimulus of the affected eye produces
an apparent dilation in both pupils since the stimulus carried through that optic nerve is weaker
PUPIL ABNORMALITIES
Anisocoria Bilateral dilation suggests anoxia ,
drug affect,.. Bilateral constriction is seen with:
Pontine hemorrhageDrugs (opiates, Clonidine)Toxins (organophosphates)
CRANIAL NERVE V
Branchs Ophthalmic branch (sensory)
Cornea, conjunctiva, ciliary body, nasal cavity, sinuses, skin of eyebrows/forehead/nose
Maxillary branch (sensory) Side of nose, lower eyelid, upper lip
Mandibular branch (mixed) Sensory – skin of temporal region, auricles, lower
lip/face, anterior 2/3 of tongue, mandibular gums/teeth Motor - innervates the muscles of mastication
CRANIAL NERVE V TESTING
Compare muscle tension bilaterally with teeth clenched
Test tactile perception Test sharp-dull discrimination Test temperature perception Test corneal reflex
Tests V & VII directly and VII consensually
CRANIAL NERVE VII
MotorMuscles of the face, scalp, and ears
AutonomicSecretion of submaxillary/sublingual glands
SensoryTaste in anterior 2/3 of tongueEar canal/postauricular
CRANIAL NERVE VII Inspect for flaccid paralysis Differentiate UMN vs. LMN
Elevate eyebrows Close eyes Show teeth Whistle Smile
Central lesions causes contralateral paralysis to lower half of face (below the eyes)
CRANIAL NERVE VIII Responsible for sense of hearing and balance Composed of the cochlear and vestibular nerves Sensory Test hearing
Conductive loss Sensorineural loss
Distortion of sound Minor Present with loss of upper tones
Noisy environment Hearing may seem to improve Hearing typically worsens
Patient’s voice Generally normal* Loud
Ear canal/TM Visible abnormality Normal
Weber Lateralizes to the impaired ear Lateralizes to the normal ear
Rinne BC > AC AC > BC
CRANIAL NERVE VIII
Look for spontaneous nystagmus Romberg test/sign
Functional test of position sense Stand with feet together Close eyes and maintain for 20-30 second
Lesion causesUnilateral deafness Imbalance
CRANIAL NERVE IX
MotorMotor : stylopharyngeus
Autonomic parotid
Sensory1/3 post. Tongue , middle ear , pharynx
Test forElevation of the uvulaGag reflexMucosal anesthesia
CRANIAL NERVE X
Cranial X Sensory : external ear Motor : pharynx , larynx , palate Autonom
Gag reflex • Afferent : IX• Efferent : X
CRANIAL NERVE XI
Provides motor to SCM upper Trapezius
Testing: Have patient shrug against resistance Head rotation and movement against resistance
CRANIAL NERVE XII Motor to tongue Testing:
Tongue movement Midline Tremors Involuntary
Atrophy Lingual speech
Paralysis causes deviation to the weak side
MOTOR FUNCTION
UMNs Transmit impulses from cortical nerve bodies to:
motor nuclei in brainstem (CNs) Anterior horn cells of spinal cord
LMNs Transmit impulses from anterior horn cells
through anterior root into peripheral nerves Terminate at the neuromuscular junction
FUNCTION AND INNERVATIONS
Muscle(s) Function Primary Nerve OriginDELTOID Shoulder abduction Axillary C5-C6
BICEPS Elbow flexion Musculocutaneous C5, C6
TRICEPS Elbow extension Radial C6, C7, C8
WRIST EXTENSORS Radial C6, C7, C8
WRIST FLEXION Median C6, C7
HAND GRIP Grasp Fingers Median C7, C8, T1
FINGER ADDUCTION Median C7-T1
FINGER ABDUCTION Ulnar C8, T1
THUMB OPPOSITION Median C8, T1
HIP FLEXION Iliopsoas L2, L3, L4
HIP EXTENSION Gluteus maximus S1
FUNCTION AND INNERVATIONS
Motor Function Muscles Primary Nerve OriginKNEE EXTENSION Quadriceps L2, L3, L4
KNEE FLEXION Hamstrings L4, L5, S1, S2
FOOT DORSIFLEXION Tibialis Anterior Deep peroneal L4, L5
ANKLE PLANTAR FLEXION
Gastrocnemius mainly S1
EXTENSION OF GREAT TOE
Extensor hallicus longus
L5
MOTOR FUNCTION Inspection
Symmetry Muscle bulk; size and contours; flat or concave; unilateral or
bilateral; proximal or distal Atrophy
Palpation Muscle tone
Percussion ? Fasciculations
Body position (during movement and at rest) Involuntary movements
Location, quality, rate, rhythm, amplitude and relation to posture, activity, fatigue, or emotions
MOTOR FUNCTION Muscle tone
Slight residual tension in normal relaxed muscle Feel muscle’s resistance to passive stretch
Muscle strength Wide variance - stronger dominant side Test by asking patient to actively resist movement If muscles too weak - test against gravity only or
eliminate gravity If patient fails to move, watch or feel for weak
contraction
GRADING MUSCULAR RESPONSE
Grade Muscular Response
0 No contraction detected
1 Barely detectable flicker or trace of contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity and some resistance
5 Active movement against resistance without
evident fatigue - “Normal”
SENSORY FUNCTION
Special attention to areas of: Symptomology Motor or reflex abnormalities Trophic changes
Confirm with repeat testing!! Patterns of testing:
SymmetricalDistal vs. proximal: scattered stimuliVary pace
SPINOTHALAMIC TRACT
Pain and temperature Crude touch (light touch
without localization) Fibers cross & pass upward
into thalamus
PAIN SENSATION
Sharp safety pin or other tool Demonstrate sharp & dull Test by:
Alternating sharp & dull w/ pt’s eyes closed Ask patient:
Sharp or dull? Does this feel same as this?
Lightest pressure needed - do not draw blood
TEMPERATURE
Often omitted if pain sensation normal Two test tubes
filled with hot & cold water or tuning fork heated or cooled by water
LIGHT TOUCH Wisp of cotton Touch lightly - avoid
pressure Ask patient:
To respond when touch is felt
Compare one area with another
POSTERIOR COLUMNS
Position and vibration
Fine touch Synapse in
medulla, cross & continue on to thalamus
TACTILE LOCALIZATION
Have pt close eyes
Touch pt on R cheek & L arm
Ask patient where touch was felt
DISCRIMINATIVE SENSATIONS
Stereognosis, graphesthesia, two-point discrimination
Test ability of sensory cortex to correlate, analyze, & interpret sensations
Dependent on touch & position sense Screen first with stereognosis - proceed to
other methods if indicated
STEREOGNOSIS Ability to identify an object
by feeling it Place familiar object in
patient’s hand & ask patient to identify it
Normally patient manipulates it skillfully & identifies it correctly
GRAPHESTHESIA
Perform if inability to manipulate object
Ability to identify numbers written in hand
Use patient’s orientation
TWO-POINT DISCRIMINATION
Touch two places simultaneously
Alternate stimuli Avoid pain Determine distance
SPINAL REFLEXES: DTRS Segmental levels of DTRs:
Supinator reflex C5, 6 Biceps reflex C5, 6 Triceps reflex C6, 7 Abdominal reflexes - upper T8, 9, 10 - lowerT 10, 11, 12 Knee (Patellar) L 3, 4 Achilles reflex S1 primarily
DEEP TENDON REFLEXES: GRADINGGrade DTR Response
4+ Very brisk, hyperactive, with clonus
3+ Brisker than average, slightly hyperreflexic
2+ Average, expected response;normal
1+ Somewhat diminished, lownormal
0 No response, absent
JENDRASSIK’S MANEUVER
Reinforcement technique
Upper extremitiesclench teethsqueeze thigh
Lower extremities lock fingers and
pull one against the other
ANAL REFLEX
Superficial reflex Loss of anal reflex suggests lesion of S2,3,4
reflex arc Possible lesion of cauda equina
CEREBELLAR FUNCTION
Requires integration of:Motor systemCerebellar
system Vestibular
systemSensory system
Assessed by:Rapid alternating
movementsFinger-to-Nose /
Heel-to-Knee Test
Romberg’s TestGait
RAPID ALTERNATING MOVEMENTS
First with hands Repeat with feet Diadochokinesia = ability to perform RAM Dysdiadochokinesis = slow, irregular, clumsy
movements
STATION, STANCE & ROMBERG’S TEST
Station & StancePt stand with feet togetherFirst, eyes open
Romberg TestThen, close eyes If okay with eyes open, but
sways w/ eyes closed = + Romberg
Mainly tests position sense Vision can compensate for loss
of position sense
PRONATOR DRIFT
Often performed in conjunction with Romberg test
Pronator drift Muscular strength Coordination Position sense
GAIT
Walk across room, turn and walk back
Tandem walking Heel & toe walking Rising from sitting position or
stepping up on stool
MENINGEAL IRRITATION
Occur with meningitis & subarachnoid hemorrhage
Brudzinski’s Sign Flex the head Marked pain in the neck Patient flexes hip and BLE
Kernig’s Sign Pain when raising a straightened LE
LAB/X-RAY CBC, CMP, U/A Specific drug levels Plain films of the spine CT of the brain & head MRI of the brain & spine
Greater resolution then CT for soft tissue/plaques
Angiography CSF exam EEG EMG & NCT PET/SPECT
CSF Obtained through lumbar puncture Indications:
Suspected CNS infection (i.e. syphilis) Suspected subarachnoid hemorrhage
Contraindicated if cerebral mass/lesion is suspected
Measure opening pressure Obtain samples for cell counts, glucose,
protein level, and cultures
COMPUTED TOMOGRAPHY Gives adequate information about brain anatomy Used primarily to detect hemorrhage & tumors Can be performed with/without contrast Indications:
Focal neurologic deficits Altered mental status Head trauma New-onset seizure Increased ICP Suspected mass lesion Suspected subarachnoid hemorrhage (with contrast) Abscess, intracranial tumor (with contrast) Chronic subdural hematoma, infarct,
vascular malformation
REVIEW OF NEUROLOGICAL EXAM
Six categories: Mental status & speech Cranial nerves Motor function Sensory function Reflexes Cerebellar function
Carefully evaluate the hx of the CC CN assessment is essential!
SUMMARY Select appropriate questions to elicit from the patient with a
neurological complaint during a patient interview Differentiate “normal” from “abnormal” findings on
neurological examination Identify common causes of various cranial nerve palsies Differentiate conductive hearing loss from sensorineural hearing
loss Differentiate amongst the various movement disorders Differentiate atrophy, hypertrophy, and pseudohypertrophy. Differentiate between spasticity, rigidity, and flaccidity, and
identify common causes of each. Determine location of neurological lesion
Differentiate upper motor neuron lesions from lower motor neuron lesions
Differentiate CNS disorders from PNS disorders, and identify location of the lesion & common causes.
Compare and contrast the five clinical levels of consciousness.