Nervous System to be unbiased and objective

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1. History Taking And Physical Examination In Nervous System Dr.Jafer M(GP)

2. Learning objective At the end of this lesson, the student should be able to: Mention main symptoms in nervous system abnormalities Show techniques of cranial nerves and motor system examination Aassess level and content of consciousness Identify clinical features of upper motor neuron lesion from lower motor neuron lesion

3. History taking Major symptoms in nervous system Disturbance of speech (dysphasia/aphasia) Episodes of loss of consciousness Disturbance in vision, hearing, swallowing Weakness of extremities Abnormal body movement Bladder and bowel dysfunction Abnormal sensory symptoms

4. Cont… Abnormal body movement Seizures Seizure is paroxysmal event due to abnormal, excessive, hypersynchronous discharges from an aggregate of central nervous system neurons Epilepsy is recurrent seizures due to chronic, underlying process in the brain cortex

5. Cont… Was it a seizure or not ? If yes, was it associated with loss of consciousness? Was there prodromal phase?, which begins hours to days before the seizure, and manifests with irritability, headache,insomnia , bad temper, depression or manic behavior Was there preceding aura? Presence of preceding aura signals focal onset of the seizure, and presents with extreme fear, strange epigastric sensations , dream-like experiences, unpleasant smells

6. Cont… Was there post ictal syndrome?, which may be brief or last for several hours, and manifests with headache, irritability , confusion, drowsiness, muscle ache/soreness, paralysis altered speech/aphasia, altered behaviors or emotional outbursts Age at onset, frequency and duration of the attack (fit), the time of day or night that the seizure occurs, behaviors and feelings during the attack, history of anti seizure drug use (what drug/s, how long in use, effect of medication-reduced or controlled the seizure)

7. Cont… Endogenous factors: Family history of epilepsy, geneti susceptibility for epilepsy Epileptogenic factors: History of head injury, stroke, brain tumor, CNS infections, degenerative CNS diseases

8. Cont… Common causes of seizure in adults Head injury Alcoholism (Binge alcohol intake or alcohol withdrawal) Brain tumor, Cerebrovascular disease Metabolic disorders such as uremia, hepatic failure Degenerative central nervous system (CNS) diseases such as Alzheimer’s disease CNS infections such as meningitis, encephalitis idiopathic

9. Cont… Hemiparesis Weakness of ipsilateral upper and lower extremities Crossed paralysis: Ipsilateral cranial nerve sign with contralateral hemiparesis Causes of hemiparesis a. Acute hemiparesis (onset in minutes to hours) Head injury (intracranial hemorrhage) Cerebral stroke (ischemic or hemorrhagic stroke) .Bleeding into the brain tumor

10. Cont… b. Subacute hemiparesis (onset in days to weeks) Subdural hematoma, Brain abscess Cerebral toxoplasmosis and primary CNS lymphoma in AIDS pts c. Chronic hemiparesis (onset in months) Tuberculoma Neurocysticercosis , Brain tumor Chronic subdural hematoma Degenerative CNS diseases

11. Cont… Causes of paraparesis Usually caused by spinal cord disorders a . Acute paraparesis (onset in hours) Acute transverse myelopathy (ATM) eg . Transverse myelitis Spinal cord injury (spinal shock ), Spinal cord infarction b. Subacute or chronic paraparesis (onset in weeks to months) Disc prolapse or herniation Pott’s disease ( tuberculous spondylitis )

12. Physical examination mental status Appearance and behaviour Mood Speech and language Cognitive function Level of consciousness: is assessed by Glasgow Coma Scale (GCS), numerical value to the patient’s responses to defined stimuli Assessment variables and scores of GCS Eye opening Spontaneous --- 4 , To speech --- 3 , To pain --- 2 , None --- 1

13. Cont… B.Best verbal response Oriented --- 5, Confused --- 4, Inappropriate speech --- 3, incomprehensible sound --- 2, None ---1

14. CONT C.Best motor response Obeys command --- 6, Localizes pain -- 5, Normal withdrawal --4 Abnormal flexion --- 3 , Abnormal extension --- 2, None --- 1 Total score out of 15

15. Cont… 2.Cranial nerves Location of cranial nerves Cranial nerve 1 and 2 are central nervous tissue Cranial nerve 3 and 4 --- Mid brain Cranial nerves 5-8 --- Pons Cranial nerves 9-12 --- Medulla Cranial nerves never cross, except trochlear nerve, and clinical findings are always on the same side of affected cranial nerves

16. Cont… 1.The frist cranial nerve( olyfactory ) It used for smelling 2 . The second cranial (Optic) nerve arises from the retina and ends at the occipital visual cortex . It caries the sense of sight. It is tested by examination of:- 2.1 Testing of the visual fields a) Confrontation method - Stand and sit a meter away from patient who looks fixedly at your nose, while covering the other eye

17. Cont.. 2.2 Visual acuity: - may be checked by Snellen’s chart (see special exam in the next chapter) Use finger counting and reading. 2.3 Checking for colour vision

18. Cont… 3. Third, fourth, and sixth cranial nerves The third ( oculomoter nerve) arises from the mid brain. Its functions are Give motor supply to all extra ocular muscles except lateral rectus and superior oblique Supply the lavator palpebrae superioris , ocularis muscle Supply the pupilary constrictor muscles and muscles of accommodation of the lens. The fourth ( troclear ) nerve: - supplies the superior oblique muscle The sixth ( abducent )-nerve: - supplies the lateral rectus muscle Pupilary light reflex

19. Cont… 4 .The fifth cranial (Trigeminal) nerve:- It has motor and sensory components Sensory part has three sub- branches Ophthalmic Maxillary and Mandibular divisions Corneal reflex- Motor examination of jaw movement -Patient is asked to extend the jaw, move it from side to side, and bite strongly

20. Cont… 5 . The seventh (facial) nerve: - has two major functions Motor branch supplies all muscles of facial expression Sensory branch supplies taste buds of anterior 2/3 of the tongue Evaluation of the motor function Inspection for flattening of the nasolabial fold, facial droop or asymmetry Then ask the patient to Frown, raise eye brows Close his eye tightly against pressure, Smile or show upper teeth, Blow cheek

21. Cont… 6 . The eighth (vestibule-cochlear) nerve: - it mediates the sense of hearing and also important for rotational perception and keeping balance. Testing Cochlear portion is done by assessing the ability to hear using:- Whispered and spoken voice, tickling of a watch etc

22. Cont… 7 . The ninth cranial ( glosso pharyngeal) nerve mediates Taste sensation from the posterior 1/3 of the tongue Motor supplies to muscles of the pharynx Examination includes -Checking for taste over the posterior third of the tongue. -A portion of the ninth nerve and a portion of the tenth nerve are tested by the gag reflex , elicited by stimulating the posterior tongue with a tongue depressor

23. Cont… 8 . The tenth cranial ( vagus ) nerve mediates If a unilateral lesion is present, the uvula will deviate from the lesion to the side opposite . Hoarseness of the voice and difficulty in swallowing, as well as repeated . Coughing after swallowing liquid, suggest the possibility of vagal involvemen

24. Cont… 9 . The eleventh cranial (accessory) nerve : The patient is then asked to turn his chin against the examiner’s resisting hand , first to one side and then to the other . 10. Twelfth cranial (hypoglossal) nerve: - Innervates muscles of the tongue. It is evaluated by observing the movements of the tongue

25. Cont… 3. The Examination Of Motor Function The examination of motor function includes evaluation of muscle bulk, strength, tone, coordination ’ and reflexes. Inspection The muscles of the limbs are specifically observed for Resting position of the limbs Size Symmetry Presence of atrophy Fasciculations (fine twitching movements) and Involuntary movements such as a tremor

26. Cont… Testing for muscle tone This can be accomplished by movement of the limbs passively at every joint while the patient is completely relaxed . Muscle tone may be Normotonic : - found in normal individuals Hypotonic: - found in patents with lower motor lesion, spinal shock etc. Hypertonic (spasticity / rigidity):-this may be of different type e.g. Clasp knife rigidity which may be found an upper motor lesions Cog- Wheel rigidity which is found in Parkinsonism.

27. Cont… Muscle power Muscle power grading scale 0= no movement 1= flickering of fingers 2= horizontal motion on bed 3= movement against gravity (vertical motion) 4= movement against gravity and power 5= full powe

28. Cont… DEEP TENDER REFLEXES Knee jerk reflex, Triceps reflex, Ankle reflex SUPERFICIAL REFLEXES The superficial abdominal reflex The cremasteric reflex Plantar reflex : - is tetrad by scratching the sole of the patient's foot from the heel toward the toes and observes the moment of the toes. The response could be Normal :- downward ( plantar ) flexion of all toes Equivocal :- no response Up going plantar ( Babinisky’s Sign):-. An upward movement of the great toe with fanning or spreading of the other toes. This is a pathological reflex which is often found in Upper motor neuron lesions

29. Cont… 4.SENSORY EXAMINATION Peripheral sensations like pain, temperature, pressure touch, special, and vibration are affected in all lesions below the cortex including the thalamus .

30. Cont… Pain and temperature sensation tests ( spinothalamic ) Pain sensation is tested with a sterilized pin. -Temperature tested by using hot and cold test tubes Position and vibration sensation tests (posterior column) Position sense or proprioception is tested by asking the patient to close eyes , and the examiner moves the patient’s finger or toe up or down while the patient interprets the action -Vibratory test needs a tuning fork which is placed over bony prominences such as the wrist , elbow, medial malleoli , patellae, anterior superior iliac spine, spinuos processes and clavicle.

31. Cont… CENTRAL (CORTCAL) SENSATION The cortical sensation is also referred to as central or discriminative sensation. In lesions of the cortex the peripheral sensations like pain, temperature, pressure, touch, and vibration are not affected. 1- Sterognosis -identify objects by touching while the eyes are closed 2- Graphstesia -identify numbers or letters written on the skin surface with eyes closed 3- Two point differentiation-identify two closely approximated stimuli as separate. 4- Point localization with the eyes closed

32. Comparison of lower (LMN) and upper motor neuron (UMN) lesion Variables LMN lesion UMN lesion Fasciculation present absent Atrophy present none, mild Tone hypotonia hypertonia Reflex hyporeflexia hyperreflexia Plantar reflex no respons Upgoing / Babinski +

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