final Neurological physical examination.pptx

final Neurological physical examination.pptx

1. Neurological examination

2. Neurological examination After completing this session , you will be able to: Identify pertinent neurologic system history questions Obtain neurologic system history Perform a physical assessment of the neurologic system Differentiate between normal and abnormal findings

3. Structure and Function Nerves carry information to and from CNS: Sensory ( a fferent) messages from sensory receptors to CNS Motor ( e fferent) messages from CNS to muscles and glands Nervous system divided into:

4. Central Nervous System Brain Consists of: cerebrum (or cerebral cortex), brainstem, cerebellum Cerebral cortex Center for a human's highest functions, memory, reasoning, sensation & voluntary movement Each half of cerebrum is a hemisphere

5. Each hemisphere is divided into four lobes: Frontal- Personality, behavior, emotions & intellectual function Parietal - Sensation Temporal- hearing, taste & smell Occipital -Vision Central Nervous System….

6. Brainstem- has three areas: Midbrain —Most anterior part of brainstem. It contains many motor neurons and tracts Pons — Containing ascending sensory and descending motor tracts Medulla —It has vital autonomic centers (respiration, heart, GI function) and nuclei for cranial nerves VIII through XII Central Nervous System….

7. Cerebellum Located under occipital lobe concerned with coordination of voluntary movements, equilibrium & muscle tone Central Nervous System….

8. Spinal cord Extends from upper border of first cervical vertebra to lower border of first lumbar vertebra Primary pathway for messages traveling between peripheral areas of body and brain It’s encased & protected by a continuation of meninges and cerebrospinal fluid of brain It’s also protected by bony vertebrae of spine Central Nervous System….

9. Consists of: Spinal nerves 31 pairs (efferent and afferent nerves) Named after region of spine they exit ( 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal) Cranial nerves 12 pairs Peripheral Nervous System

10. Autonomic Nervous System Contains motor neurons that regulate activities of visceral organs and affect smooth, cardiac muscles & glands It consists of two parts: Sympathetic division , which controls fight-or-flight reactions Parasympathetic division , which restore and maintains normal body functions

11. Subjective Data…. Headache ? Head injury ? Dizziness (lightheaded)/ Vertigo (spinning)/ Syncope , a temporary loss of consciousness? Seizures (altered or loss of consciousness, involuntary muscle movements)? Difficulty swallowing: Dysphagia

12. Tremors (involuntary shaking, vibrating or trembling)? Weakness ? Paresis: partial or incomplete paralysis Paralysis: total loss of motor function due to lesion in the neurologic or muscular system Incoordination. Any problem with balance when walking? Dysmetria: inability to control distance, power and speed of muscular action

13. Subjective Data… Numbness or tingling (Does it feel like pins and needles) Paresthesia: abnormal sensation, e.g., burning & tingling Difficulty speaking ? Dysarthria: difficulty forming words Dysphasia: difficulty with language comprehension or expression Past history of stroke, spinal cord injury, meningitis, encephalitis or congenital defect?

14. Objective Data Sequence for complete neurologic examination: Mental status Cranial nerve function Sensory function Motor function Reflexes

15. Mental Status- ABCT A ppearance: posture, body movements, dress, grooming & hygiene B ehavior: level of consciousness (awake, alert, aware), facial expression, speech, mood & affect C ognitive function : orientation (time, place, person), attention span, recent & remote memory T hought process and perception: thought process and content, perceptions, screen for anxiety disorders, depression & suicidal thoughts

16. Appearance 1.Posture ; is erect and position is relaxed. 2.Body movement ; body movement are voluntary ,deliberate ,coordinate and smooth and even. 3. Dress ;appropriate for setting, season, age gender and social group Clothing fits and put on appropriately . 4. Grooming and hygiene ; the person is clean and well groomed, hair is neat and clean.

17. Behavior - Level of consciousness  Conscious = fully alert having a clear sensorium  Drowsy = light sleep, easily arousable & alert for a brief period  Stupor = only a brief & incomplete arousal even by vigorous stimuli  Comatose = pt cannot be aroused  the Glasgow’s scale

18. Behavior- Facial expression the look is appropriate to the situation and change appropriately with the topic. Comfortable eye contact unless precluded with cultural norm. Observe the face, both at rest and when the patient is interacting with others. Watch for variations in expression with topics under discussion. Are they appropriate? Or is the face relatively immobile throughout?

19. Behavior- Speech Quality ;the person makes laryngeal sounds effortlessly and shares conversation appropriately. The pace of the conversation is moderate, the stream of talking is fluent. Articulation ( ability to form words)is clear and understandable. Word choice is effortless and appropriate to educational level. The person complete sentences occasionally pausing to think

20. Behavior- Mood and affect Using your observations of facial expressions, voice, and body movements, assess the patient’s affect. Does it vary appropriately with topics under discussion, or is the affect labile, blunted, or flat? Does it seem inappropriate or extreme at certain points? If so, how? Note the patient’s openness, approachability, and reactions to others and to the surroundings.

21. Cognitive function Orientation ; Awareness of personal identity, place, and time. To person = his name, name of relatives, friends, known persons To place = where now, address, town / city, zone, region … . T o time = time, day, date, week, month, year

22. Cognitive function Immediate memory = to repeat a list of 3 items e.g. pencil, car, bird Recent memory = ask to recall the 3 items 5, 15min later Remote Memory = ask schools, jobs held, known past events ……

23. Cognitive function Digits span to repeat series of numbers Usually 5 digit, if performed, 6, 7. If 7 digits Ok, stop testing. Spelling Backward a five-letter word e.g. W-O-M-E-N Arithmetic calculations from 100, subtract 7 & keep subtracting 7... multiply 5 by 13

24. Thought and Perceptions Thought Processes. Assess the logic, relevance, organization, and coherence of the patient’s thought processes as they are revealed in words and speech throughout the interview. Does speech progress in a logical manner toward a goal? The person should complete the thought.

25. Thought and Perceptions Thought Content. Follow appropriate leads as they occur rather than using stereotyped lists of specific questions. For example, “You mentioned a few minutes ago that a neighbor was responsible for your entire illness. Can you tell me more about that?” Or, in another situation, “What do you think about at times like these?” What the person says should be persistent and logical

26. Thought and Perceptions Perceptions; Inquire about false perceptions in a manner similar to that used for thought content. For example, “When you heard the voice speaking to you, what did it say? How did it make you feel?” Or, “After you’ve been drinking a lot, do you ever see things that aren’t really there?” The person should be consistently aware of reality

27. Thought and Perceptions Suicidal thoughts When the person expresses feeling of sadness,hoplessness or despair or grief, it is important to assess any possible risk of physical self harm. Begin with general questions, if you hear affirmative answers continue with more specific questions Have you ever felt so blue you thought of hurting your self? Do you feel like hurting your self now? Do you have a plan to hurt your self ?

28. Mini mental status exam The mini mental state examination is a simplified scored form of cognitive function . It is quick and easy ,includes a standards set of 11 questions and requires only 5 to 10 minutes to administer It should initial and serial measurement so you can demonstrate worsening or improvement . Concentrates only on cognitive functioning.

29. Thought and Perceptions

30. Interpretations Any score greater than or equal to 27 points (out of 30) indicates a normal cognition. Below this, scores can indicate severe (≤9 points), moderate (10–18 points) or mild (19–24 points) cognitive impairment.

31. Cranial nerves ( cn ) Nerve Name Superficial Exit Level CN I Olfactory Olfactory bulb [superior to brainstem] CN II Optic Optic chiasm [superior to brainstem] CN III Oculomotor Medial midbrain CN IV Trochlear Dorsal midbrain CN V Trigeminal Pons CN VI Abducent Pons CN VII Facial Pons CN VIII Vestibulocochlear Rostral medulla CN IX Glossopharyngeal Rostral medulla CN X Vagus Rostral medulla CN XI Accessory Spinal C1-C6 CN XII Hypoglossal Rostral Medulla

32. Test Cranial Nerves I-Olfactory nerve (sensory) / smell With client's eyes closed , occlude one nostril and present an aromatic substance Use familiar, obtainable and non-noxious smells such as coffee, toothpaste, orange, or soap Ask client to sniff and identify it. Normally, a client can identify an odor on each side of the nose II-Optic nerve (sensory) / vision Assess visual acuity (Snellen chart & Rosenbaum card) Assess visual field (confrontation)

33. Formal test: Snellen’s chart = normally pt is at 6 meter e.g. 6 / 60 - if <6/60, nearer distance, 5, 4, 3, 2, 1meters If <1/ 60, test with: Counting fingers (CF) Hand movements (HM) Perception of light (PL)

34. Visual acuity using snellen chart

35. 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

36. Hand held visual acuity card( Rosenbaum chart )

37. Cont. . . Visual fields Confrontation test (measure peripheral vision) Visual fields are tested by asking the patient to look directly at you whilst you wiggle one of your fingers in each of the four quadrants. Ask the patient to identify which finger is moving. Moving both fingers at the same time can test visual inattention and checking the patient identifies this.

38. Visual fields

39. The Oculomotor nerve (CN III), Trochlear nerve (CN IV) and Abducent Nerve(CN VI) Test Extra ocular Movements of eyes Test direct and consensual pupillary reaction to light Accommodation

40. Eyes – Techniques of Examination 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

41. Eyes – Techniques of Examination Accommodation An object held about 10 cm from the client’s nose

42. Assess motor function Palpating temporal and masseter muscles as client clenches teeth; muscles should feel equally strong on both sides Next try to separate jaws by pushing down on chin; normally you cannot Assess sensory function With client's eyes closed, test light touch sensation by touching a cotton wisp on client's face: forehead, cheeks & chin Ask client to say “Now” whenever the touch is felt V-Trigeminal nerve (motor and sensory)

43. (motor and sensory) / facial expression and taste Assess motor function Note mobility & facial symmetry as client responds to these requests: smile, frown, close eyes tightly, lift eyebrows, show teeth and puff cheeks Press client 's puffed cheeks in; note that the air should escape equally from both sides Assess sensory Function Placing items with various tastes on anterior portion of client’s tongue (e.g., sweet, sour & bitter) . VII-Facial nerve

44. VIII-Vestibulocochlear nerve VIII-Vestibulocochlear nerve [Acoustic] (sensory) / hearing To assess this nerve, use whispered voice test, Weber’s test and Rinne test Whisper a few words from just behind one ear. The patient should be able to repeat these back accurately. Then perform the same test for the other ear. Alternatively, place your fingers approximately 5 cm from one ear and rub them together. The patient should be able to hear the sound generated. Repeat for the other ear.

45. VIII-Vestibulocochlear nerve.. Weber Test Place a vibrating tuning fork on the forehead or midline of the skull . Ask the patient where they hear the sound: Normal: Equal in both ears.

46. VIII-Vestibulocochlear nerve.. Rinne Test: Strike a tuning fork and place it on the mastoid process (bone conduction). When the patient no longer hears it, move it near the ear canal (air conduction). Normal (Rinne positive): Air conduction > bone conduction.

47. VIII-Vestibulocochlear nerve.. Romberg test: Ask the patient to remain still and close their eyes (for about 20 seconds). If they sway or lose balance , it suggests vestibular dysfunction

48. IX-Glossopharyngeal nerve and X- Vagus nerve -motor and sensory Depress tongue with a tongue blade and note pharyngeal movement as client says “ ahhh ” ; Normal: Uvula stays midline, soft palate elevates symmetrically. Then, check gag reflex by touching the tip of a tongue blade against posterior pharynx Normal: Gag response present. Ask client to drink water & note swallowing

49. (motor) / neck muscles Ask the patient to turn their head to one side against resistance (place your hand on their jaw and push while they resist). Normal: Strong resistance with no asymmetry. Then, ask client to shrug both shoulders against resistance Normal: Strong, symmetrical shoulder elevation. XI-Spinal accessory nerve

50. XII-Hypoglossal nerve Motor) / Tongue Inspect the tongue. No wasting or tremors should be present Note the forward thrust in the midline as client protrudes tongue Ask client to say “light, tight, dynamite”. Note that lingual speech (l, t, d,n ) is clear and distinct

51. 1 Pain Use a sharp object (e.g., broken cotton swab). Ask if the sensation is " sharp or dull ". Sensory function 52

52. 2. Light Touch Use a cotton wisp or soft tissue. Gently touch different areas and ask the patient to say " yes " when they feel it. Sensory function….

53. Sensory function…. 3. Temperature Use warm and cold test tubes. Ask the patient to distinguish between hot and cold .

54. 4. Vibration Use a tuning fork on bony prominences (e.g., wrist, elbow, ankle). Ask when the vibration starts and stops. Sensory function….

55. 5. Position (Kinesthesia) The test is done with eyes closed Move a finger or toe up and down and ask the patient to identify the direction. Normally, a client can detect movement Sensory function….

56. 6. Stereognosis (Object Recognition) Place a familiar object (e.g., key, coin) in the patient’s hand and ask them to identify it. 7. Graphesthesia (Number Recognition) Draw a number (e.g., 3, 5) on the patient’s palm and ask them to identify it. Sensory function….

57. 8. Extinction Ask the client to close the eyes Simultaneously touch both sides of body at same point Ask client to state how many sensations are felt and where they are Normally, both sensations are felt Sensory function….

58. Motor Function Assess muscles for size , strength , tone and involuntary movement Cerebellar function ( Coordination and skilled movements tests and balance tests)

59. Motor Function Assess muscles for size , strength , tone and involuntary movement 1) Size Assess all muscle groups and compare left to right side Atrophy: small muscles occurs with disease & in-activity Hypertrophy: increased size exercise 2) Strength Test power of muscles groups simultaneously Paresis : weakness Paralysis or plegia : absence of strength

60. Muscle strength is graded on a 0 to 5 scale: 0—No muscular contraction detected 1—A barely detectable flicker or trace of contraction 2—Active movement of the body part with gravity eliminated 3—Active movement against gravity 4—Active movement against gravity and some resistance 5—Active movement against full resistance without evident fatigue. This is normal muscle strength.

61. Motor Function …. 3) Muscle Tone (Normal degree of tension [contraction]) Instruct client to “go loose”, move each extremity smoothly through a full range of motion Note pain or limited range of motion Normally, you will note a mild, even resistance to movement 4) Involuntary movements Normally not occur, if present note location, rate, frequency and amplitude (tic, tremor)

62. Coordination and skilled movement Rapid alternating movements test Finger-to-finger test Finger-nose-finger test Heel-to-shin test Normally, clients movements are accurate, rhythmic pace and coordinated Any abnormal findings in these test stand for lack of coordination Motor Function ….

63. Balance tests 1) Gait Observe as client walks 10 to 20 feet, turns and returns to starting point. Normally, client moves with a sense of freedom Ask client to walk a straight line in a heel-to-toe fashion ( tandem walking ). Normally, client can walk straight and stay balanced Motor Function …. Ataxia : uncoordinated, unsteady gait

64. 2)Romberg Test Ask client to stand up with feet together and arms at sides Once in a stable position, ask him or her to close eyes and to hold position Wait about 20 seconds Normally, a client can maintain posture & balance Motor Function ….

65. Assessment of Reflexes A reflex is defined as an immediate and involuntary response to a stimulus. They occur due to the presence of intermediate neurons between the sensory and motor nerve ends in the spinal cord. Reflexes are of two type Superficial /cutaneous/ reflexes Deep tendon reflexes

66. Deep Tendon Reflexes… Reflexes Commonly Tested: Biceps Reflex (C5-C6) : Tap the biceps tendon at the elbow; forearm flexes. Triceps Reflex (C7) : Tap the triceps tendon above the elbow; forearm extends. Brachioradialis Reflex (C5-C6) : Tap the brachioradialis tendon at the wrist; forearm flexes. Patellar Reflex (L3-L4) : Tap the patellar tendon below the knee; leg extends. Achilles Reflex (S1-S2) : Tap the Achilles tendon at the heel; foot plantarflexes.

67. Scale for Grading Reflexes Deep tendon reflexes should be graded on a scale of 0-4 as follows : =0 absent despite reinforcement = 1 present only with reinforcement = 2 normal = 3 increased but normal = 4 markedly hyperactive, with clonus

68. Deep tendon reflexes Biceps reflex (C5 to C6) Support client 's forearm on yours; this position relaxes and partially flexes client's arm Place your thumb on the biceps tendon and strike a blow on your thumb Normally, contraction of biceps muscle and flexion of forearm Deep tendon reflexes

69. 2- Triceps reflex (C7 to C8) Tell client to let arm “just go dead” as you suspend it by holding upper arm Strike triceps tendon directly just above elbow Normally , extension of forearm Deep tendon reflexes ….

70. Brachioradialis reflex (C5 to C6) Hold client ’s thumb to suspend forearm in relaxation Strike forearm directly about 2-3 cm above the radial styloid process Normally, flexion and supination of forearm Deep tendon reflexes …

71. 4- Quadriceps reflex (Knee Jerk) (L2 to L4) Let lower legs dangle freely to flex the knee and stretch the tendons Strike tendon directly just below patella Normally, extension of lower legs. You will feel contraction of quadriceps Deep tendon reflexes ….

72. 5- Achilles reflex (Ankle Jerk) (L5 to S2) Position the client with knee flexed and hip externally rotated Hold foot in dorsiflexion and strike Achilles tendon directly Dorsiflex foot and tap the tendon Normally, Foot planter flexes against your hand Deep tendon reflexes…

73. Plantar reflex (L4 to S2) With reflex hammer, draw a slow stroke up lateral side of sole of foot and inward across ball of foot, like an upside-down J Normally, plantar flexion of toes and inversion and flexion of forefoot Superficial reflexes

74. Glasgow coma scale (GCS) Accurate and reliable quantitative tool and objective assessment that defines level of consciousness by giving it a numeric value Divided into three areas: eye opening, verbal response and motor response; fully alert person has a score of 15

75. Abnormalities in Muscle Movement Paralysis: Decreased or loss of motor power caused by problem with motor nerve Patterns of paralysis

76. Abnormal Finding: Meningeal irritation Brudzinski’s sign Kernig’s sign Positive Brudzinski’s and Kernig’s signs indicate meningeal irritation (which occur with meningitis)

77. Sample Charting Subjective Data No unusually frequent or severe headaches; no head injury, dizziness or vertigo, seizures, or tremors. No weakness, numbness or tingling, or difficulty swallowing or speaking. Has no past history of stroke, spinal cord injury, meningitis, or alcohol disorder.

78. Objective Data Motor: No atrophy, weakness, or tremors. Rapid alternating movements—finger-to-nose smoothly intact. Gait smooth and coordinated, able to tandem walk, negative Romberg Sensory: Sharp and dull, light touch, vibration intact. Stereognosis—able to identify key Reflexes: No Babinski sign, DTRs 2+ and = bilaterally with downgoing toes Mental status: Appearance, behavior, and speech appropriate; alert and oriented to person, place, and time; recent and remote memory intact

79. Objective Data Cranial nerves: II: Vision 20/20 left eye, 20/20 right eye; peripheral fields intact by confrontation; fundi normal. III, IV, VI: EOMs intact, no ptosis or nystagmus; pupils equal, round, react to light and accommodation (PERRLA). V: Sensation intact and equal bilaterally; jaw strength equal bilaterally. VII: Facial muscles intact and symmetric. VIII: Hearing—whispered words heard bilaterally. IX, X: Swallowing intact, uvula rises in midline on phonation. XI: Shoulder shrug, head movement intact and equal bilaterally. XII: Tongue protrudes midline, no tremors.

80. References Lynn S. Bickley, Peter G. Szilagyi, Richard M. Hoffman. Bates’ guide to physical examination and history taking.13 th edition. Philadelphia: Wolters Kluwer;2021 Carolyn Jarvis, Ann Eckhardt. Physical Examination & Health Assessment. 8 th edition. St. Louis, Missouri: Elsevier Inc;2020