hx & physical e xam in neurology. hx localization phenomenology hx etiology ph.e localization,...

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HX & PHYSICAL EXAM IN NEUROLOGY

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HX & PHYSICAL EXAM IN NEUROLOGY

HX

Localization Phenomenology HX etiology PH.E localization ,

categorization

IMPORTANT FACTORS

Chief complaint Severity Mode of onset Progress Exacerbating and…

WHERE IS THE LESION

Focal Multifocal System disorder

LOCALIZATION

CNS vs. PNS Brain/Brain stem Spinal cord Peripheral nerves

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

FOCUSES

Mental statusCranial nervesMotor functionReflexesSensory statusCoordination and balance

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

GLASGOW COMA SCALE

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

VIBRATORY SENSE

128 or 256 Hz Tuning fork

If impaired, proceed proximally

PROPRIOCEPTION

Grasp toe by sides - pull away from other toes

Demonstrate “up” & “down”

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

REFLEX HAMMER

JENDRASSIK’S MANEUVER

Reinforcement technique

Upper extremitiesclench teethsqueeze thigh

Lower extremities lock fingers and

pull one against the other

BICEPS REFLEX

C5,C6Elbow Flexion

TRICEPS REFLEX

C6, C7, C8Elbow Extension

BRACHIORADIALIS REFLEXC5, C6

Forearm semiflexion/semipronation(NO wrist/hand flexion)

PATELLAR REFLEX

L2, L3, L4Knee Extension

ACHILLES REFLEX

S1, S2Ankle Plantar Flexion

PLANTAR REFLEX

L5, S1, S2

Babinski Sign

ABDOMINAL REFLEXES

T8, T9, T10:ABOVE umbilicusT10, T11, T12:

BELOW umbilicus

ANAL REFLEX

Superficial reflex Loss of anal reflex suggests lesion of S2,3,4

reflex arc Possible lesion of cauda equina

CLONUS

Rhythmic Oscillation

Flexion/Extension

UMN Lesion

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

FINGER-TO-NOSE TEST

Finger-to-nose with moving target

Stationary finger-to-nose with eyes closed

HEEL-TO-KNEE TEST

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

SPINAL STUDIES

NORMAL SKULL ANATOMY

NORMAL L-SPINE MRI

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.