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1. DISORDER OF THE NEUROLOGICAL SYSTEM

2. Anatomy and physiology of the nerves system

3. Anatomy and physiology The nervous system consists of CNS – Brain – enclosed with in the cranial cavity Spinal cord – enclosed with in the vertebral canal Peripheral Nervous System 12 Pairs of cranial nerves 31 Pairs of spinal nerves Function -Responsible for control and coordination of cellular activity

4. BRAIN Divided in to three divisions The Cerebrum The Brainstem and The Cerebellum - Contained in a rigid bony structure called the skull. - Beneath the skull the brain and spinal cord are covered by three membranes or meninges . (Dura mater, Arachnoid & Pia mater)

5. Cerebrum Responsible for an individual function and intelligence Consists two hemispheres and four lobes Gray matter – external or outer layer White matter – internal layer of the cerebrum   Four Lobes - Frontal - Parietal - Temporal - Occipital

6. Frontal Lobe The major functions of this lobe are concentration, abstract thought, information storage or memory, and motor function . It contains Broca’s area, which is located in the left hemisphere and is critical for motor control of speech . The frontal lobe is also responsible in large part for a person’s affect, judgment, personality, and inhibitions (Hickey, 2009).

7. Parietal Lobe Predominantly sensory lobe posterior to the frontal lobe. This lobe analyzes sensory information and relays the interpretation of this information to other cortical areas and is essential to a person’s awareness of body position in space, size and shape discrimination, and right–left orientation (Hickey, 2009).

8. Temporal Lobe located inferior to the frontal and parietal lobes, this lobe contains the auditory receptive areas and plays a role in memory of sound and understanding of language and music.

9. Occipital Lobe located posterior to the parietal lobe, this lobe is responsible for visual interpretation and memory.

10. Diencephalon Contain the Thalamus acts primarily as a relay station for all sensation except smell. Hypothalamus plays an important role in the endocrine system. It contains centers that regulate the sleep–wake cycle, blood pressure, aggressive and sexual behavior , and emotional responses. The hypothalamus also controls and regulates the autonomic nervous system. Pituitary Gland .

11. Brainstem Consists of the midbrain, pons and medulla oblongata Midbrain It contains sensory and motor pathways and serves as a center for auditory and visual reflexes . The Pons -Contain motor and sensory pathway and it is abridge b/n the medulla and the cerebrum. -Also contain center for controlling heart, respiration Medulla Oblongata -Transmits motor fiber from the brain to the spinal cord and sensory fiber from the spinal cord to the brain.

12. The Cerebellum Is largely responsible for smoothness & coordination of mov’t It controls balance position & fine mov’t

13. THE SPINAL CORD Serves as a connecting link b/n the brain and periphery Approximately 45 cm long, extends from the foramen magnium to the upper level of 2 nd lumber vertebra Composed of 31 pairs of spinal nerves Contains both gray and white matter

14. Blood-Brain Barrier(BBB) The CNS is inaccessible to many substances that circulate in the blood ( i.e dyes, medications, antibiotics) . Has implications in the Rx and medication selection for CNS disease processes.

15. Cerebrospinal Fluid /CSF/ A clear and colourless fluid with a specific gravity of 1.007 Produced in the choroid plexus of ventricles and circulates in the brain and the spinal cord, by the Ventricular system. It is produced at a rate of about 500 mL /day ; the ventricles and subarachnoid space contain approximately 150 mL of fluid (Hickey, 2009). The organic and inorganic content of CSF are similar to those of plasma. Analyzed for protein, glucose and chloride on routine analysis Normally, CSF has a minimal number of WBC and no RBC.

16. Peripheral Nervous System 12 Pairs of cranial nerves 31 Pairs of spinal nerves

17. Assessment of Neurological system By Blen N. (Bsc. ,Msc.)

18. objectives Common symptoms, subjective and objective data Methods of physical examination for neurological disorders Abnormal findings of neurology

19. Assessment of NS The neurological history and exam allows the examiner to pinpoint various areas of the brain or nervous system that may be dysfunctional. Specific signs and symptoms manifested by the patient are associated with specific areas of the brain.

20. Cont… Integrate the steps of the neurological history with the steps taken during the complete physical examination. It may not be necessary to perform the entire neurological exam on a patient with no suspicion of neurological disorders. perform a complete, baseline neurological examination on any patient that has verbalized neurological concerns in their history.

21. History & Examination The exam and history should be in an orderly, symmetrical fashion. This way, you will be certain that all areas are assessed. Each side of the body should be compared with the other side to detect any abnormalities

22. Common or Concerning Symptoms of the Nervous System Observing mental status, speech, and language Observing abstract thinking ability, speech, mood, emotional state, perceptions, thought processes, ability to make judgments Headache Dizziness or vertigo Weakness Numbness Loss of sensations Loss of consciousness Seizures Tremors or involuntary movements

23. Equipment for neurology examination Penlight Tongue blade/depressor Cotton swab & ball Tuning fork Percussion hammer Aromatic substance

24. Method of examination Sequences for complete neurologic examination Mental status assessment Cranial nerve function assessment Motor system function Sensory system function Reflexes function

25. Mental status assessment Level of consciousness Attention Orientation Language — fluency, comprehension, repetition, naming, reading, writing Memory Higher intellectual function—general knowledge, abstraction, judgment, insight, reasoning Mood and affect

26. Level of consciousness Alertness or state of awareness of the environment

27. Concentration and Attention : Evaluate based on Digit Span (recall of numbers) and attention to your questions. To test digit span, request that the patient count backwards from 100 to 50 in substracting of 7's ). Or ask the patient to name the days of the week or months of the year in reverse order, or recite the ABC's backwards. Orientation: Awareness of personal identity, place, and time(PPT). Language: A complex symbolic system for expressing, receiving, and comprehending words

28. Memory : The process of registering or recording information, tested by asking for immediate repetition of material, followed by storage or retention of information. Recent or short-term memory covers minutes, hours, or days; remote or long-term memory refers to intervals of years. Mood: Inquire how the patient feels most days: Happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious or angry.

29. Affect: Is how the patient feels or felt at any given moment: Can include a wide range of emotions like restricted , blunted, flat, inappropriate emotions. Also consider if the affect is consistent with the content of the conversation and facial expressions (e.g. pessimistic or optimistic) as well as inappropriate signs (began dancing in the office, verbally threatened examiner, cried while discussing recent happy event and unable to explain why)

30. Glasgow Coma Scale /GCS/ * Eyes Open Spontaneously 4 To Speech 3 To Pain 2 No Response 1 * Best Motor Response: Obeys 6 Localizes Pain 5 Withdraws 4 Abnormal flexion 3 Extends 2 No response 1 * Verbal Response Oriented 5 Confused Conversation 4 Inappropriate words 3 Incomprehensible Sound 2 No response 1 Total 3-15   * A score of 7 or less is generally accepted as coma and requires appropriate nursing intervention for the comatous patient.

31. Cranial nerve function assessment

32. Table 24.1 Cranial Nerves

33. Cranial Nerve I (Olfactory nerve) Its nuclei is located in Cerebral Cortex (the outer layers of the cerebrum ). It mediates the sense of smell (Mainly Sensory Function). Examination of Cranial I Function is done by testing the sense of smell.

34. CNI… Technique of Examination. Test the sense of smell using substance with familiar and non-irritating odor. Use piece of soap, fruit or other subs….. First be sure that each potency of nasal passage ways The patient should then close both eyes. Occlude one nostril and test smell in the other with familiar substance.

35. CNI… Interpretation of examination Finding. Normal – Cranial nerve I is Intact . Abnormal – Loss of sense of smell ( Ansomia ) Some causes of Ansomia (DDX) Nasal obstruction due to common cold. tumors of olfactory groove ( meningoma , frontal glioma ) Head injury

36. Cranial Nerve II (optic nerve) Located in Cerebral Cortex. it takes visual sensory in put to midbrain and optic cortex for interpretation of visual impulse.

37. CN-II… Examination of Cranial II Function I. Testing visual acuity -Distance/Central vision: Snellen eye chart -Near vision (hand-held card) Examine the Optic Fundi by using the Ophthalmoscope Note for pupillary size (3-4mm)and shape. Miosis<2mm ( hornor’s syndrom , stroke…. Mydriasis>5mm ( opiates .…. Anisocoria-pupillary asymmetry (TBI….

38. Visual acuity Distance/Central vision: Snellen eye chart; position patient 20 feet (6 meters) from the chart Patients should wear glasses if needed Test one eye at a time CN-II…

39. Eyes – Techniques of Examination Visual acuity Near vision: use (Jaeger or Rosenbaum chart (hand-held card) can also use to test visual acuity at the bedside hold 14 inches (about 30 cm) from patient’s eyes Rosenbaum chart Jaeger chart

40. CN-II Interpretation of examination Finding On the Snellen chart each line of letters is designated by a number that corresponds to the distance at which those letters can be read by someone with 'normal' distance vision. Visual acuity is expressed as a ratio, such as 20/20. The first number is the distance at which the patient reads the chart. The second number is the distance at which a person with normal vision can read the same line of the chart. 42

41. CN-II… If vision is below 1/60,make the patient to detect motion of hand in front of eye (HM) If patient can’t see HM the final test is to shine alight in to his eye , - if the patient can perceive light – record as LP. - if the patient can’t perceive light – record as NLP. 43

42. CN-II… V/A of < 3/60 in the better eye with the best possible correction – is Legally Blind. Myopia-nearsightedness Hyperopia -farsightedness DDx for causes of Visual acuity defects - i . Ocular Causes :- Refractive errors, glaucoma, Cataract, diabetic retenopathy …. - ii. Lesion of Visual Pathway:- Lesion of optic nerve , Optic tract ,visual cortex…. 44

43. CN-II Testing Visual Fields Techniques - By confrontation method :- I.e. Sit 1meter apart from the patient on same level . Make patient to look straight to your Eyes. Examine both eyes or one at a time by wiggling fingers in imaginary field of vision for both the patient & physician and compare it with yourself. 45

44. Interpretation of examination Finding Normally Intact Visual Fields Visual Field defect – Called Hemanopsia Hemanopsia -is the loss of vision in half the visual field ,usually on one side of the vertical midline caused by mostly by stroke, brain tumor and trauma 46

45. III. Light reflex sensory input is carried by optic nerve and, motor response to pupillary constrictor muscle is brought by Occlumotor nerve. Technique of examination shining torch light on one eye at a time and looking for pupillary constriction in both eyes. Interpretation of examination Finding. Normally :- Constriction of pupil on the side of light – Direct light reflex. Constriction of pupil on the other side of light – Consensual light reflex. Abnormality of Light Reflexes Absence of Direct light reflex. - Lesion of Optic N. Absence of Consensual light reflex- Lesion of CNIII. 47

46. iv. Color Vision - Tested using a chart called Ishihara Chart. - Ask the patient to differentiate green from red by reading the number. Normal Person Could Read No 74 Person with Red – green blindness couldn’t identify the number inside. 48

47. Cranial nerve lll , lV. And Vl . CN- III: check pupils for size, equality, light reaction & accommodation. Palpebral fissure (opening )for equality. Ptosis (eye lid drop) occurs in CN-III dysfunction. CN- III, IV, VI: assess extra-ocular movement to the 6 cardinal gaze. Note for deviated gaze or limited movement, or nystagmus (back & forth oscillation of the eye).

48. CN- lll , lV. And Vl . Test Extraocular Movements Test direct and consensual pupillary reaction to light Accommodation

49. Extraocular movements/six cardinal directions of gaze/wagon wheel method The client must keep the head still while following a pen that you will move in several directions to form a star in front of the client’s eyes. Always return the pen to the center before changing direction. Techniques of Examination

50. Accommodation An object held about 10 cm from the client’s nose Techniques…

51. CN- lll , lV. And Vl Interpretation of examination Finding Normal – Intact all extra ocular movement. Abnormal :-Deviation of the eyes from their normally conjugate position is termed strabismus or squint. 53 Esotropia Exotropia

52. CN- lll , lV. And Vl Other Interpretation of CNIII examination Finding Normal – Symmetrical upper eye lid movement Abnormal :- Drooping of upper lid ( Ptosis ). 54

53. Trigeminal nerve assessment (CN-V) Trigeminal N/CN-V : is a mixed nerve(sensory and motor) Mainly sensory innervations to face via its three main division (Ophthalmic, maxillary,& Mandibular branches) The sensory portion mediates facial sensetion and the sensory part of cornea. The Motor innervates muscles of mastication (temporal and masseter Muscles)

54. CN-V Sensory function: with the pt’s eye closed, test light touch sensation by touching a cotton wisp to these designated areas on pt’s face: forehead, check, chin. Ask the pt to tell you when ever the touch is felt. Note for decreased or unequal sensation. Corneal Reflex: with a pt looking forward, bring cotton wisp in from side to minimize blinking, lightly touch the cornea. Normally, the pt will blink bilaterally. No blink occurs with a lesion or paralysis of CN-V

55. CN-V Bilaterally palpate temporal and masseter muscles while patient clenches teeth (Sensation) Ask client to close the eyes and test forehead, each cheek, and jaw on each side for sharp or dull (use a cotton swab) sensation. Direct the client to say ‘now’ every time the cotton is felt. (Reflex) With the individual's eyes open and looking upward, the practitioner takes a strand of cotton, approaches the cornea from the side, and touches it with the cotton. This should initiate a blink response. Both eyes should be tested independently.

56. CN-V Interpretation of examination Finding loss of sensation ( paresthesia ) exaggerated sensory perception ( Hypersthesia ) Diminished corneal reflex Deviation of jaw to side of lesion when mouth opens. Some of causes for abnormal finding (DDX) Brain stem lesion Pontine lesion (intracranial hemorrhage) Infection of trigeminal ganglion Trigeminal neuralgia. 58

57. Facial nerve assessment (CN-VII) Motor function: Note for facial symmetry as the pt respond to these requests: smile, frown, close eyes tightly against you attempt to open them, lift brow, show teeth, & puff checks, then press the puffed cheeks in, the air should escape equally from both side. Muscle weakness shown by loss of nasolabial fold , dropping of one side of the face, lower eye lid sagging Loss of movement & asymmetry occur with both CNS & peripheral nerve lesion (Bell’s palsy).

58. CN-VII Technique of examination Smile Frown iii. Puff out both cheeks. Iv . Close both eyes tightly & try to open them and look for strength of muscles. 60

59. CN-VII Sensory Function: do not test routinely. When indicated, test sense of taste by applying to the tongue with small amount of sugar, salt, or lemon juice. Ask the person to identify the taste.

60. Interpretation of examination Finding Normal – Intact facial muscles Abnormal findings - Upper motor lesion (due to, stroke, tumor, trauma…) results in Lower face muscle paralysis 62

61. Interpretation … Lower motor lesion (due to, Viral infection of facial nerve, …) results in all facial muscle paralysis. 63

62. Cranial nerve VII palsy 64

63. Cranial nerve Vlll ( Acoustic) Located in Pons it is mainly sensory - Cochlear division – hearing. - Vestibular division- Balance.

64. CN- Vlll Examination of function of CN VIII. By testing the following I. Auditory Acquity Technique :- Close both eyes and ,and examine one ear at a time by closing the other by whispering or tickling of watch from 30c.m away. II. Examine Air and Bone Conduction – if hearing is impaired to differentiate conductive or sensorineural hearing loss. Using the following tests 66

65. CN- Vlll A. Test for lateralization (Weber test ). Place the base of the lightly vibrating tuning fork firmly on top of the patient’s head or on the mid forehead. Ask where the patient hears it: on one or both sides. Normally the sound is heard in the midline or equally in both ears Interpretation of finding In unilateral Conductive Hearing loss :- Sound is heard (lateralize to) impaired ear. B/c Impaired won’t be distracted by environmental noise. 67

66. 68 Causes of Conductive Hearing loss - Acute ottits media, perforation of ear drum …. In unilateral Sensorineural Hearing loss :- Sound is heard (lateralize to) good ear. Causes of Sensorineural Hearing loss Occupational acoustic trauma , head injury….. Conductive Hearing loss VS Sensorineural loss

67. B. Compare air conduction (AC) and bone conduction (BC) ( Rinne test). Place the base of a lightly vibrating tuning fork on the mastoid bone, behind the ear and level with the canal. When the patient can no longer hear the sound, quickly place the fork close to the ear canal and ascertain whether the sound can be heard again.. Normally the sound is heard longer through air than through bone (AC > BC). 69

68. 70 Interpretation of finding - In unilateral Conductive Hearing loss :- BC is longer than Air conduction.(BC > AC),B/c bone conduction by passes conductive pathway. - In unilateral Sensorineural Hearing loss :-.(AC > B C), b/c it passes through less resistant than bone like normal

69. Cranial IX and X (gloss pharyngeal and vagus ) Cranial IX and X. – Nuclei in Medulla Gloss pharyngeal (CN-IX) - Motor—pharynx - Sensory—posterior portions of the eardrum and ear canal, the pharynx, and the posterior tongue, including taste (salty, sweet, sour, bitter) Vagus (CN X) - Motor—palate, pharynx, and larynx - Sensory—pharynx and larynx 71

70. Cranial IX and X Ask the client to open the mouth, depress the client’s tongue with the tongue blade, ask the client to say ”ah” . Usually, the soft palate raises and the uvula remains in the midline

71. Examination of function of CN IX &X - Technique:- examine the following - Palatal movement (tell the patient to say “Aha”) - Check gag reflex with spatula - Notice phonation Abnormal findings – Deviation of palatal movement, absent gag reflex. Causes : Head trauma, Medullary lesions 73 Cranial IX and X

72. Spinal accessory (CN-XI) Function - Motor—the sternomastoid and upper portion of the trapizus. Examination of function of CN XI - Examine rotation of head & neck against resistant Loss of Resistance :- sternomastoid muscle weakness 74

73. - Examine Shrugging of shoulder against resistant. - Loss of Resistance :- trapizus muscle weakness Note for atrophy, muscle weakness or paralysis. 75 CN-XI

74. Hypoglossal Nerves: XII

75. Cranial nerve XII ( Hypoglossal nerve) located in medulla Function :- Motor to Tongue muscles Examination of function of CN XII - Examine - tongue protrusion ,look for fasciculation(spontaneous contraction). - Symmetry - Strength - Wasting 77

76. Areas of the Neurologic System Assessment Sensory function Observation of light touch identification Sharp, dull determination Stereognosis (object identification) Graphesthesia (Number identification)

77. Sensory function Assess to identify various sensory stimuli. It tests intactness of Pain Nerve fiber, sensory tract, & higher cortical discrimination This is done when making sure the pt’s is alert, cooperative, & comfortable. Otherwise you may get misleading & invalid results. Spinothalamic tract: testes the pt ability to perceive a pain prick (with sharp & dull prick). By saying “sharp” or “Dull” Hypoalgesia (decreased pain sensation), analgesia (absent pain sensation), hyperalgesia (increased pain sensation)

78. Sensory function Temperature: Test temperature sensation only when pain sensation is abnormal. Fill two test tube one with hot water & the other cold water place the bottom ends to the pt skin. Ask the pt “which temperature felt?” Light touch: Apply a cotton wisp to the skin on arms, forearms, hands, chest, thighs, & legs. Ask pt to tell when touch felt. Hypoesthesia (decreased touch sensation), anesthesia (absent), hyperesthesia (increased)

79. Evaluation of light touch. -Use wisp of cotton to touch the skin lightly on both sides simultaneously. -Test several areas on both the upper and lower extremities. -Ask the patient to tell you if there is difference from side to side or other "strange" sensations.

80. Sensory function Vibration test: assess the pt. ability to feel vibration of tuning fork over bony prominence. Place the vibrating tuning fork over the bony surface of finger nail ( interphalangeal joints ) & ask to indicate the vibration “start & stop”. If no vibration felt, move to proximal test such as, ulnar process, & ankles, patella, iliac crests. Unable to feel it occurs in peripheral neuropathy( nerves that carry messages to and from the brain and spinal cord from and to the rest of the body are damaged or diseased.)

81. Sensory function Position (kinesthesia): used to test the pt ability to perceive passive movement of the extremity. Move the toe up & down, ask which way is moved, when the pt’s eyes are closed. Can observe loss of position sense. Tactile discrimination: test discrimination ability of the sensory cortex. Problem occurs with lesion of the sensory cortex Stereo gnosis : a test to recognize objects by feeling their size, form, & weights. Done with pt closed eyes. Astreognosis (sensory impairment) inability to identify objects correctly.

82. Testing the client’s ability to identify sharp sensations . -Ask the client to say “sharp” or “dull” when something sharp or dull is felt on the skin. -Touch the client using random locations. Testing the client’s ability to identify dull sensations Testing the client’s ability to identify sharp sensations

83. Testing stereognosis using a coin -Use as an alternative to graphesthesia . -Place a familiar object in the patient's hand (coin, paper, pencil, etc.). -Ask the patient to tell you what it is.

84. Sensory function Graphesthesia : ability to read a number by having it traced on the skin. Inability to distinguish the number occurs with lesions of the sensory cortex

85. Testing graphesthesia (Number identification) -With the blunt end of a pen or pencil, draw a large number in the patient's palm. -Ask the patient to identify the number.

86. Inspect & palpate Motor system Muscles: inspect all muscle group for size, compare one side with the other. If muscle in extremity looks asymmetry measure each in non- stratching tape & record the difference. A difference of 1cm or less is not significant. Note for muscle atrophy occurs with disuse, lower motor neuron disease, & muscle disease; hypertrophy occurs in isometric exercise

87. Inspect & palpate Motor system Tone: normal degree of tension. To test this, move the extremities through a passive range of motion. First, persuade the pt to relax completely, then move smoothly through full ROM. Note for even resistance to movement. Limited ROM, pain with motion, flaccidity (decreased resistance), spasticity & rigidity (increased resistance) Involuntary movement: normally no, if present note the location, frequency, rate, amplitude. Tic, tremor & fasciculation (muscle twitch) are involuntary movement.

88. Inspect & palpate Motor system Strength- flexion and extension at the elbow by applying appropriate force Extension of the wrist Grip Finger abduction by trying to force them together Opposition of thumb –little finger while you resist Hip flexion-anterior thigh Hip extension –posterior thigh Hip abduction and adduction NOTE strength

89. Cerebellar function Balance test: Gait: observe as a pt walks up to 20 feet, turns & returns to the starting point. Note for stiff posture, wide base, lack of arm swing, unequal rhythm of steps, slapping foot, scraping of toe of shoe, ataxia (uncoordinated or unsteady gait). Ask pt “ tendem walking” (heel-to-toe) fashion. Crooked line of walk, wide base, reel, loss of balance are noted. Coordination test Romberg’s test: Positive Romberg’s sign is loss of balance that increase by closing eye. Observe sways, fall, widens base of feet to avoid falling. (cerebellar dysfunction)

90. Areas of the Neurologic System Assessment Motor function Observation of gait and balance Administration of the Romberg test Administration of the finger-to-nose test Observation of rapid alternating action movements

91. Observation of gait and balance Ask the client to walk across the room and return

92. Romberg’s test for balance. Ask the patient to remain still and close their eyes (for about 20 seconds).

93. Finger-to-nose test. - Ask the client to extend both arms from the sides of the body -ask the client to keep both eyes open -ask the client to touch the tip of the nose with right index finger, and then return the right arm to an extended position. -ask the client to touch the tip of the nose with left index finger, and then return the left arm to an extended position. -Repeat the procedure several times. -Ask the client to close both eyes and repeat the alternating movements

94. Observation of rapid alternating action movements - Ask the client to sit with the hands placed palms down on the thighs. -Ask the client to return the hands palms up. -Ask the client to return the hands to a palms-down position. -Ask the client to alternate the movements at a faster pace. Testing rapid alternating movement, palms up. Testing rapid alternating movement, palms down.

95. Inspect & palpate Motor system Rapid Alternating Movement (RAM): ask the pt to pat the knees with both hands, lift up, turn hand over, & pat the knee with the back of hands, and to do this faster. Lack of coordination, slow, clumsy response occurs with cerebellar disease. Alternatively , ask the pt to touch the thumb to each finger on the same hand. Normally, done quickly. finger-to-finger Test: pt is with open eye. Ask to use index finger to touch your finger, then his/her nose. Observe for missed spot.

96. Inspect & palpate Motor system Finger-to-Nose Test: ask the pt to close the eyes & to stretch out the arms, and to touch the tip of own nose with each index finger. Normally, this is done with fast & smooth movement. Note for missing spot Heel-to-Shin Test: test lower extremity coordination by asking the pt to be in supine position, to place the heel on the opposite knee, & run it down the skin from the knee to the ankle. Heel fall off shin is lack cerebellar function

97. Reflex test Stretch or deep tendon reflexes (DTRs): reveals the intactness of the reflex arc at specific spinal level. For adequate response, the limb should be relaxed the muscle partially stretched. Stimulate the reflex by a short snappy blow of reflex hammer on to the tendon. Compare right and left side responses should be equal.

98. Reflex response grade 4+ = very brisk, hyperactive with clonus (involuntary muscle contraction ), indicative of disease 3+ = brisker than average, may indicate disease 2+ = average, normal 1+ = Diminished, low normal 0 = no responce

99. Areas of the Neurologic System Assessment Reflexes ( Stimulus-response activities of the body.( Biceps Triceps Brachioradialsis Patellar (knee) Achilles Plantar (Babinski). Abdominal

100. ( A) Biceps reflex.

101. Biceps Reflex C5 – C6 Support the person’s forearm on yours; this position relaxes & partially flexes. Place thumb on the biceps tendon & strike a blow on your thumb. Feel the normal response, which is flexion of the forearm

102. (B) Triceps reflex.

103. Triceps reflex C7 – C8 Tell the person to let the arm “just go dead” Suspend it by holding the upper arm Strike the triceps tendon directly just above the elbow. The normal response is extension of the forearm Alternately, hold the pt’s wrist across the chest to flex the arm at the elbow, & tap the tendon

104. ( C) Patellar reflex.

105. Patellar reflex L2 – L4 Quadriceps Reflex (knee jerk) Let the lower legs dangle freely & stretch the tendon Strike the tendon directly just below the patella Normal response, extension of the lower leg is the expected response And palpate contraction of the quadriceps.

106. ( D) Ankle or Achilles reflex

107. Ankle reflex L5 – S2 Achilles reflex (“Ankle jerk”): Position the pt with the knee flexed Hold the foot in dorsiflexion , & strike the Achilles tendon directly. Feel the normal response as the foot planter flexes against your hand. In supine position, flex one knee & support that lower leg against the other leg. Dorsiflex the foot & tap the tendon

108. Babinski reflex Indicative of central nervous system disease affecting the corticospinal tract (control mov’t of limbs ) If the lateral aspect of the sole of the foot is stroked, the toes contract and are drawn together . In patients who have central nervous system disease of the motor system, however, the toes fan out and are drawn back . This is normal in newborns but represents a serious abnormality in adults.

109. Testing the plantar reflex (Babinski). -Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key. -Observe for planter flexion of the foot .

110. (E) Babinski response

111. Abdominal reflex testing pattern. -Use a blunt object such as a key or tongue blade. -Stroke the abdomen lightly on each side in an inward and downward direction. -Note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus.

112. Abdominal reflex It is Upper T8 – T10 & Lower T10 – T12 Have a pt assume supine position, with the knees slightly bent. Use the handle of the reflex hammer or wood applicator or the end of tongue blade to stroke the skin, Move from side toward midline of the abdomen Normal response is ipsilateral contraction of abdominal muscle with observed deviation of the umbilicus. Superficial reflexes are absent with disease with like cerebrovascular accident

113. Infants reflexes Rooting reflex: brush the infant cheek, note infant turns head toward that side & open the mouth Sucking reflex: touch the lip & offer gloved little finger, note strong sucking Palmar grasp: offer your finger from ulnar side, note tight grasp. Planter grasp: touch your thumb at bell of the baby’s foot. Note that toes curl down tightly Babunski reflex: the toes fan out and are drawn back . Tonic neck Reflex: baby with supine, turn head to one side with the chin over shoulder Moro reflex: while quickly lowered the head, the baby looks as if hugging a tree. Abduction & extension of the extremity, funning finger, & curling of the index finger

114. Glasgow Coma scale (GCS) This assesses the functional state of the brain as a whole. The scale is divided in to three areas: Eye opening Motor response Verbal response The total score reflects brain’s functional level. Fully alert score 15, score 7 or less reflects coma

115. Special assessment Special assessment for Meningitis patients Positive Kernig’s sign: When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended if you try to extend pain will occur. Positive Brudzinski’s sign: When the patient’s neck is flexed, flexion of the knees and hips is produced; when passive flexion of the lower extremity of one side is made, a similar movement is seen in the opposite extremity

116. Thank you