Remaining Neurologic System

Review of Systems Decreased LOC Confusion Headache/Pain History of head injury

or major trauma Clumsiness/decreased

coordination or balance Seizures Fainting spells Dizziness

Physical disability Numbness or tingling Sudden change in

vision or hearing Behavioral changes

Attention, mood, speech, insight, judgment, orientation, or memory

Psychiatric symptoms Aphasia

Complete Neurological Assessment Cerebral Function

Mental Status Cranial Nerve Function Sensory Function Motor Function Reflexes

Sensory Function

Sensory Function- A&P Review

Common Sites for Referred Pain

© Pat Thomas, 2006.

Dermatomes A band of

skin innervated by the sensory root of a single spinal nerve

Sensory Function-Spinothalamic Tract

Superficial sensation Pain

Assess sharp and dull Allow at least 2 sec

between Temperature

Test only when pain sensation abnormal

Light (crude) touch Apply wisp of cotton

to arms, forearms, hands, chest, thigh, an legs

Sharp and dull and light touch intact

Sensory Function-Spinothalamic Tract

Scatter stimuli so as to sample most dermatomes and peripheral nerves Both shoulders (C4) Inner and outer aspects of forearm (C6, T1) Thumbs and little finger (C6, C8) Front of both thighs (L2) Medial and lateral aspects of both calves (L4, L5) Little toe (S1) Medial aspect of each buttock (S3)

Sensory Function-Posterior Column Tract

Deep sensation Vibration

Use low pitch tuning fork (128 0r 256Hz)

Place over bony surface of fingers and great toe Vibration intact

Position (Kinesthesia) Move finger or big toe

up or down and ask which way move Kinesthesia intact

Sensory Function-Posterior Column Tract

Discriminatory sensations Stereognosis

Recognize objects Stereognosis intact.

Graphesthesia Read number traced on

hand Graphesthesia

intact Two-point discrimination

Distinguish separation of two stimuli No longer

perceives two separate points at ___mm

Motor Function

Motor Function- A&P Review

Motor Function- Muscles

Muscle size & symmetry Palpate major muscle groups of arms & legs

Muscle Tone While at rest and with passive movement

Normal, flaccid, spastic, or rigid

Muscle Strength Muscle Strength Testing

Arm Flexion & Extension Grip Strength Hip Flexion & Extension Thigh Adduction and Abduction Knee Flexion & Extension Ankle Dorsiflexion & Plantar Flexion

Ask to lift extremity against gravity and the against resistance 5/5- Full ROM against gravity, full resistance

4/5- Full ROM against gravity, some resistance 3/5- Full ROM with gravity 2/5- Full ROM with gravity eliminated (passive) 1/5- Slight contraction 0/5- No contraction No atrophy, weakness,or tremors

Motor Function- Cerebellar Function Balance tests

Gait Walk 10-20 feet, turn,

and walk back the other way Gait smooth &

coordinated Tandem walk

Able to tandem walk

Romberg Test Feet together, arms at

side, and eyes closed and hold 20 seconds

No swaying = negative Romberg

Motor Function- Cerebellar Function Coordination & Skilled Movements

Rapid alternating movements (RAM) Patient pats knees with front and back of

hands quickly Rapid alternating movements quick and accurate

Finger-to-finger test Touch thumb to each finger on same hand

quickly Watch for cerebellar tremor (intention tremor)

Tremor of extremity that occurs at end of purposeful mvmt. Caused by lesion/damage to cerebellum from stroke, tumor, MS, inherited degenerative disorders

Finger to finger test smooth and accurate

Motor Function- Cerebellar Function Touch thumb to each finger on

same hand Thumb opposition quick and

accurate

Finger-to-nose test With eyes closed patient

touches tip of his/her nose quickly with index finger, alternating hands Finger to nose smooth and

accurate

http://www.youtube.com/watch?v=90a5cI7wDcY&feature=related

Reflexes

Reflexes- A&P Review

Reflexes Deep Tendon Reflexes (DTR)

Biceps (C5-C6) Triceps (C7-C8) Brachioradialis (C5-C6) Quadriceps (Patellar) (L2-L4) Achilles (L5-S2)

Superficial Reflexes Plantar Reflex/Babinski (L4-S2) Abdominal Reflexes

(Upper T8-T10) (Lower T10-T12)

Crematic Reflex (L1-L2)

Biceps Reflex Place your thumb or

finger firmly on the biceps tendon.

Strike with the reflex hammer so that the blow is aimed through your thumb toward the biceps tendon

Observe flexion at the elbow, and watch for and feel the contraction of the biceps muscle Biceps reflex 2+ bilaterally

Triceps Reflex Strike the triceps

tendon above the elbow

Watch for contraction of the triceps muscle and extension at the elbow Triceps reflex 2+

bilaterally

Brachioradialis Reflex Strike forearm

approximately 2-3cm above radial styloid process

Watch for flexion and supination of the forearm Brachioradialis reflex

2+ bilaterally

http://www.youtube.com/watch?v=3zUm0uWn6cE&feature=related

Quadriceps (Patellar) Reflex Briskly tap the patellar

tendon just below the patella

Note contraction of the quadriceps with the extension at the knee Patellar reflex 2+

bilaterallyhttp://www.youtube.com/watch?v=_GS2bMQLgPw&feature=fvwrel

Achilles Reflex Dorsiflex the foot at

the ankle Have the patient relax Strike the Achilles

tendon Watch and feel for

plantar flexion at the ankle Achilles reflex 2+

bilaterally

Plantar Reflex Stroke the lateral aspect

of the sole from the heel to the ball of the foot, curving medially across the ball

Note movements of the toes, normally plantar flexion

Plantar reflex with down going

toes/Negative Babinskihttp://www.youtube.com/watch?v=oI_ONptx2Ns&feature=related

Basic Neurological Exam/Recheck

Affect Level of Consciousness

Degree of wakefulness/ responsiveness to environment Orientation Speech Pattern Facial Symmetry Ability to Follow 1 Step Commands Direct & Consensual Pupillary Response & Accomodation Hand Grasps & Foot Pushes

Testing for Meningitis Kernig’s sign

In supine position flex knee and hip of one leg to 90 degrees, then gently try to straighten leg. Positive if pain in low back and hamstring and of knee

won’t straighten more than 135 degreesNegative Kernig’s sign http://www.youtube.com/watch?v=rJ-5AFuP3YA&feature=related

Brudzinski’s sign In supine position place one hand behind patient’s

neck and lift off of bed trying to touch chin to chest. Positive if hips and knees involuntarily flex Negative Brudzinski’s sign