Neurological assesement.ppt one type of

nuerological assessment

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NEUROLOGICAL EXAMINATION
BY: SOLOMON. B (MSc, AHN)
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Objectives
At the end of this class the learner should be able to
Explain the common Neurological symptoms
Perform an assessment of Neurologic system
Interpret Neurological findings
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OVERVEIW OF A/P NERVEOUS SYSTEM
The nervous system consists of two divisions:
The central nervous system (CNS)
The brain and spinal cord.
The peripheral nervous system, made up of
the cranial and spinal nerves.
12 pairs of cranial nerves
31 pairs of spinal nerves (8 cervical,12 thoracic, 5
lumbar, 5 sacral, and 1 coccygeal)
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OVER VEIW OF A/P NERVEOUS SYSTEM
cont’d
Theperipheralnervoussystemdividedinto
Thesomatic,orvoluntary
Theautonomic,orinvoluntary
Sympatheticandparasympathetic
Thefunctionofthenervoussystemistocontrolall
motor,sensory,autonomic,cognitive,and
behavioralactivities.
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Neurological Examinations
Common Neurologic symptoms
Loss of consciousness
Seizure (convulsion)
Visual Disturbances
Syncope (Fainting)
Weakness or paralysis of part of the body (paresis and plegia)
Abnormal body movements like tremor,
Neurologic pain
Altered or loss of sensation
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Neurological Examinations
Includes
Assessment cerebral function.
Assessment of cranial nerves.
Assessment of motor system.
Assessment of sensory system.
Assessment of the reflexes.
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7. Neurological Examinations cont’d
I. Assessing Cerebral Function
Cerebral abnormalities may cause disturbances in
Mental status,
Intellectual functioning,
Thought content
Patterns of emotional behavior.
There may also be alterations in perception, motor and
language abilities,
A. MENTAL STATUS
Observing the patient’s appearance and behavior
dress, grooming,and personal hygiene.
Posture, gestures, movements, facial expressions..
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Neurological Examinations
B. INTELLECTUAL FUNCTION
A person with an average IQ can repeat seven digits without
faltering and can recite five digits backward.
Eg: Ask the patient to count backward from 100 or to subtract
7 from 100, then 7 from that, and so forth (called serial 7s)
The capacity to interpret well-known proverbs
Tests abstract reasoning, which is a higher intellectual
function
Can the patient make judgments about situations
Eg:If the patient arrived home without a house key, what
alternatives are there?
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Neurological Examinations
THOUGHT CONTENT
During the interview, it is important to assess the patient’s
thought content.
Are the patient’s thoughts spontaneous, natural, clear,
relevant, and coherent?
Does the patient have any fixed ideas, illusions,,
delusion ,hallucination,
What are his or her insights ?
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Neurological Examinations
EMOTIONAL STATUS
An assessment of cerebral functioning also includes the
patient’s emotional status. Is the patient’s affect (external
manifestation of mood) natural and even, or irritable and
angry, anxious, apathetic or flat, or euphoric?
Does his or her mood fluctuate normally, or does the patient
unpredictably swing from joy to sadness during
the interview? Is affect appropriate to words and thought
content?
Are verbal communications consistent with nonverbal cues?
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Neurological Examinations
PERCEPTION
Agnosia is the inability to interpret or recognize objects
seen through the special senses.
The patient may experience auditory or tactile agnosia as
well as visual agnosia.
The patient is shown a familiar object and asked to
identify it by name.
E.g: Placing a familiar object (eg, key, coin) in the
patient’s hand and having him or her identify it with both
eyes closed is an easy way to assess tactile interpretation.
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Neurological Examinations
LANGUAGE ABILITY
The person with normal neurologic function can understand
and communicate in spoken and written language. Does the
patient
answer questions appropriately? Can he or she read a
sentence
from a newspaper and explain its meaning? Can the patient
write
his or her name or copy a simple figure that the examiner has
drawn? A deficiency in language function is called aphasia.
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Neurological Examinations cont’d
Cognitive function
Orientation to time, place, and person.
A change in the patient’s LOC is the earliest and most sensitive
indicator that his neurologic status has changed
Ex :what is your name?(Orientation to person)
What is today’s date ?( Orientation to time)
Where are you now? (Orientation to place)
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Neurological Examinations cont’d
Assess the three aspects to memory
Immediaterecall by saying a series of numbers and having
the patient repeat them.
Recent memoryby asking the patient to recall something
after 5 minutes has elapsed.
Remote memoryrefers to events in the distant past.
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Neurological Examinations cont’d
Assessment of level of consciousness
The Glasgow Coma Scale
It is an objective method
A score of seven or less is accepted as coma
depends on the
eye opening, best motor response
verbal response.
(the deepest come) to 15 (the full alertness).
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Neurological Examinations cont’d
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Peripheral nerves
2. Cranial Nerves
There are 12 pairs of cranial nerves.
Most cranial nerves innervate the head, neck, and special sense
structure.
Three are entirely sensory(I, II, VIII), five are motor(III, IV,
VI,XI, and XII), and four are mixed(V, VII, IX, and X) .
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Neurological Examinations cont’d
Examination of the Cranial Nerves
Of the 12 CNs, some are named according to their
function.
Examples of these are the Olfactory (smell), Optic (vision),
Oculomotor (eye movements),
Abducens (abduction of the eye),
Facial (facial expression), and vestibulocochlear (hearing
and balance) nerves.
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Neurological Examinations cont’d
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Neurological Examinations cont’d
Assessment of the Cranial nerves
Cranial nerve I (Olfactory nerve)
Ask the patient to identify substances with his eyes closed.
First be sure that each nasal passage is open by
compressing one side of the nose
Asking the patient to sniff through the other.
The patient should then close both eyes.
Occlude one nostril and test smell in the other with such
substances as a peal of an orange, coffee, soap
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Neurological Examinations cont’d
CompletelossofthesenseofsmelliscalledAnosmia
Anosmiamostcommonlyfollowsseveretraumaticbraininjury,
Mayalsobeduetofrontaltumors,
Particularlyolfactorygroovemeningioma,
postinfectiousabnormalitiesofthenasalmucosa,eg.cold
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Neurological Examinations cont’d
Cranial nerve II (Optic nerve)
Test visual acuityfor far vision and near vision using
Snellen chart (eye chart),
reading news paper at 35 cm for near vision.
Using hand held card (held @ 14 inches) or Snellen wall
chart, assess each eye separately.
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Con’t…..
Visual acuity is expressed as two numbers (e.g., 6/6):
the first indicates the distance of patient from chart, and
the second, the distance at which a normal eye can read the line of
letters.
The human finger is about the same size as the top letter
on the chart
counting fingers at 6 meters is about equal to 6/60 vision
If vision is below 1/60, use the patient to detect motion of
hand in front of the eye; ‘hand motion’ (HM)
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Con’t….
If the patient can’t see HM, the final test is to shine a light
into his eye
If he can perceive light –LP
If he can’t perceive light –NPL
Interpretation of V/A, the WHO classification of Visual
impairment and blindness
6/6(1.0) -6/18(0.3): Normal
<6/18(0.3) -6/60(0.1): Visual impairment
<6/60(0.1) -3/60(0.05) : severe Visual impairment
<3/60(0.05) -NPL : blindness
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Neurological Examinations cont’d
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Neurological Examinations cont’d
Examine visual fieldsby confrontationThe visual fields
can be roughly assessed in the neurologist’s office or at the
bedside with so-called finger perimetry (or digital
confrontation),.
The examiner sits directly in front of the patient and the
patient fixes one eye on the examiner’s nose.
The examiner then moves a finger in each of the four
quadrants of the visual field, testing each eye separately.
The patient is asked whether he or she can see the finger
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Neurological Examinations cont’d
Inspect the optic fundiwith your ophthalmoscope, paying
special attention to the optic discs .
Ophthalmoscope is used for Inspection of the optic nerve
papillae (optic discs) .
Abnormal:indicates
Optic nerve lesion,
Papilledema,
Enlarged retinal veins
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Neurological Examinations cont’d
Cranial nerve III ( Oculomoter nerve)
Test pupillary reaction.
CNs 2&3 -Pupilary Response
Pupils modulate amount of light entering eye (like shutter on
camera lens)
Dark conditions :dilate; Bright :constrict
Direct response = constriction in response to direct light
Consensual response = constriction in response to light shined in
opposite eye
Light impulses travel away (afferents) from pupil via CN 2 &
back (efferents) to cilliary muscles that control dilatation via
CN 3
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Neurological Examinations cont’d
Describing Pupilary Response
Normal recorded as: PERRLA(Pupils Equal, Round,
Reactive to Light and Accommodation)
with accommodation = to constriction occurring when eyes
follow finger brought in towards them, directly in middle
(i.e. when looking “cross eyed”).
Abnormal responses can be secondary to: direct
or indirect damage to either CN 2 or 3
Medications e.g. sympathomimetics (cocaine),Atropine dilate;
narcotics (heroin)constrict.
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Neurological Examinations cont’d
Oculomoteralsosupplythelavatorypalpebrae,ocularis
muscle.
Ptosis:Mayindicatedamagetocranialnervethree,which
helpstoopentheeyelidandtokeepitopened
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Neurological Examinations cont’d
CranialnerveIII,IV,andVI,(Oculomotor,
trochlear,andabducentnerves)
Thethird,fourth,andsixthcranialnervesarechecked
together
Oculomoternervesupplyfourextraocularmuscles
theeye(superiorrectus,inferiorrectus,inferioroblique,
medialrectusmuscle)
Alsoraiseslid&mediatespupilaryconstriction.
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Neurological Examinations cont’d
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Neurological Examinations cont’d
Pupils (assessment of cranial nerves III,)
Inspect for equality, size, and shape relation to light and
accommodation.
Troclear nerve(fourth) Supplies the superior oblique of
the eye muscle
Abducent nerve (sixth)supplies the lateral rectus of the
eye muscle.
Test for extra ocular movement of the eye.
Eyemovementsaretestedbyhavingthepatientkeepthe
headstationaryandfollowtheexaminer’sfingerwithhisor
hereyes.
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Neurological Examinations cont’d
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Neurological Examinations cont’d
Cranial nerve V (Trigeminal nerve)
Sensory part
The corneal reflex test (the blinking reflex)
Test for facial sensation.
Motor part
Test for Jaw movements.
While palpating the temporal and masseter muscles.
Ask the patient to clench his or her teeth.
Note the strength of muscle contraction.
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Neurological Examinations cont’d
Testing temperature sensation. By two test tubes,
filled with hot and cold water, ask to identify by
closing the eye
Test for light touch, using a fine wisp of cotton. Ask
the patient to respond whenever you touch the skin.
Test the corneal reflex. Ask the patient to look up and
away from you.
Approaching from the other side, touch the cornea
lightly with a fine wisp of cotton. .
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Neurological Examinations cont’d
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38. Neurological Examinations cont’d
Cranial nerve VII (facial nerve)
Motor function
Assess the face for symmetry ,Mobility
Test for facial movements such as frowning, whistling,
smiling etc..
Lift eye brows and show upper teeth.
The ability of the eyes to remain closed against your
resistance.
Sensory function
Test for tasting ability of the anterior 2/3 of the tongue
(using sugar, salt solution )
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Neurological Examinations cont’d
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Neurological Examinations cont’d
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Neurological Examinations cont’d
Cranial nerve VIII (auditory nerve)
Test for hearing.
Voice test –Rub fingers next to either ear; whisper &
ask ptrepeat words,
Assess hearing. If hearing loss is present,
Test for lateralization,(Weber Test)
Test for conductive hearing loss (RinneTest)
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Neurological Examinations cont’d
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43. Neurological Examinations cont’d
Rhinetest
Normallythesoundisheardlongerthroughairthantbone(AC
>BC)
Inconductivehearinglosssoundisheardthroughboneaslong
asorlongerthanitisthroughair(BC=ACorBC>AC).
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Neurological Examinations cont’d
Cranial nerve IX (Glosso pharyngeal): mixed
Test for tasting ability of the tongue for bitter taste (posterior
1/3)
Motor : pharyngeal muscle: swallowing, Note the rise of the
soft palate and Uvula
Cranial nerve X (Vagus nerve): mixed
Sensation in external ear, pharynx and thoracic
swallowing.
Note the rise of the soft palate and Uvula.
Test for gag reflex.
Parasympathetic innervation of abd organ, thoracic
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Neurological Examinations cont’d
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Neurological Examinations cont’d
Cranial nerve XI (spinal accessory nerve)(Motor)
Test for movement of the shoulder and neck
Innervates sternocleiod mastoid and trapezius muscles
Palpate and note strength of trapezius muscles while patient
shrugs shoulders against resistance.
Palpate and note strength of each sternocleidomastoid
muscle as patient turns head against opposing pressure of
the examiner’s hand.
.
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Neurological Examinations cont’d
Cranial nerve XII (hypoglossal nerve)(Motor )
Inspect the tongue for Symmetry and movement.
Inspect the tongue, note: wasting , tremors, fasciculation
Lesions of this nerve produce atrophy and weakness of
the tongue.
A unilateral lesion usually produces the tongue deviates to
the weaker side
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Neurological Examinations cont’d
3. Assessment of Motor System
In motor system assessment focuses on:-
Body position (Gait and station)
Involuntary movements.
Characteristics of muscle (Bulk, Tone or Strength
(Power).
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Neurological Examinations cont’d
Muscle strength is assessed and rated on a five-point
scale in all four extremities.
5/5. Normal full strength, muscle is able to move
actively against the effects of gravity and applied
resistance.
4/5-muscle is able to move actively against the effect
of gravity with weakness to applied resistance.
3/5muscle is able to move with support against effect
of gravity alone.
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Neurological Examinations cont’d
2/5Muscle is able to move with gravity eliminated.(able to
move from side to side)
1/5 Muscle contraction is palpable and visible trace or
flicker movement occur.
0/5Muscle contraction movement is not detectable.(no
muscle contraction)
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Neurological Examinations cont’d
Muscle Tone
Tone is the normal degree of tension (contraction) in
voluntarily relaxed muscles.
It shows as mild resistance to passive stretch.
To test muscle tone, move the extremities through a
passive range of motion.
When tone decreasesTone (hypotonic).
The muscles are soft, flabby or flaccid.
Increased muscle tone exists: if the muscles are
resistance to movement.(spasticity),Rigidity
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Neurological Examinations cont’d
Assessment of Coordination and Movement Balance
Coordination is smooth, accurate performance of motor
activity.
Testing coordination in the upper extremities include
Finger-to-finger test.
Finger-to-nose test
Rapid alternate movement of the hands.
Testing coordination in the lower extremities include:
Heel to-shin test.
Done by having patient to run the heel down the anterior
surface of the tibia, Test each leg in turn)
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Neurological Examinations cont’d
Examination for Balance
Romberg’s test:
Ask the person to stand up with feet together and arms at
the sides, once in a stable position,
Ask the person to close the eyes and to hold the position,
wait about 20 seconds
Normally posture and balance are maintained.
Positive Romberg’s signs, loss of balance occurs with
cerebral ataxia, alcoholic intoxication)
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Neurological Examinations cont’d
4. Assessing for Reflex
Reflexes are movements produced in body parts when
hammering a tendon in a body.
Two types of reflex.
Superficial or cutaneous reflexes.
Deep tendon or muscle-stretch reflexes.
Superficial or cutaneous reflexes are elicited by cutaneous
or mucous membrane stimulation.
EX: Abdominal reflex, plantar reflex, corneal reflex,
pharyngeal (gag) reflex, cremasteric reflex. ( male)
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Neurological Examinations cont’d
Abdominal Reflex
Stroke patient’s abdomen diagonally from upper and lower
quadrants toward umbilicus.
Normal response :
Contraction of rectus abdominis.
Umbilicus moves toward stimulus.
Cremasteric Reflex
Gently stroke inner aspect of a male’s thigh.
Normal response: Testes rise.
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Neurological Examinations cont’d
Deep Tendon (muscle stretch) reflexes
Are elicited by striking a muscle’s tendon of insertion using
a reflex hammer.
Example –upper limbs Normal response
Biceps (C5 C6) Forearm flexion
Triceps (C7, C8 Forearm extension
Lower Limbs
Patellar /knee Jerk (L3, L4) leg extension
Plantar flexion of the foot
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57. The Plantar Response (L5, S1)
With an object such as a key or the wooden end of an
applicator stick, stroke the lateral aspect of the sole from
the heel to the ball of the foot, curving medially across the
ball.
Note movement of the toes, normally flexion.
Normal Response: (absent babinski’s response) is plantar
flexion of the toes.
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58. The Plantar Response (L5, S1)
Dorsiflexion of the big toe, often accompanied by fanning
of the other toes, constitutes a Babinski response.
It often indicates a central nervous system lesion in the
corticospinal tract.
A Babinski response may also be seen in unconscious
states due to drug or alcohol intoxication or in the
postictal period following a seizure.
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59. Reflexes …
The reflex response is graded on a 4-point scale.
4+Very brisk, hyperactive, with clonus
(rhythmic oscillations between flexion and extension)
3+Brisker than average; possibly but not necessarily
indicative of disease
2+ Average; normal
1+Somewhat diminished; low normal
0No response
Clonus: is the presence of rhythmic involuntary contractions,
most often at the foot and ankle.-----CNS involvement/injury
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Neurological Examinations cont’d
5. Assessment of Sensory :
Pain and temperature
Position and vibration
Light touch.
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Neurological Examinations cont’d
Pain.
Use a sharp safety pin or other suitable tool.
Ask the patient, “Is this sharp or dull?”or, when making
comparisons, “Does this feel the same as this?” Apply the
lightest pressure needed for the stimulus to feel sharp,
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Temperature.
Use two test tubes, filled with hot and cold water, or a
tuning fork heated or cooled by water.
Touch the skin and ask the patient to identify “hot” or “cold.
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Neurological Examinations cont’d
ASSISSIN FOR VIBRATION
Place a vibrating tuning fork over a finger joint, and then
over a toe joint.
Ask patient to tell you when vibration is felt and when it
stops.
Diminished/absent vibration sense:
Peripheral nerve damage caused by alcoholism, diabetes, or
damage to posterior column of spinal cord.
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Neurological Examinations cont’d
Assessment for Stereognosis
With patient’s eyes closed, place a familiar object, such as
a coin or a key, in patient’s hand, and ask patient to identify
it.
Test both hands using different objects.
Stereognosisintact bilaterally.
A b n o r m a l f in d in g s
Abnormal findings suggest a lesion or other disorder
involving sensory cortex or a disorder affecting posterior
column.
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Neurological Examinations cont’d
AssessmentofGraphesthesia
Assessmenttecniques
Withpatient’seyesclosed,usepointofaclosedpento
traceanumberonpatient’shand,andaskpatientto
identifythenumber.
Graphesthesiaintactbilaterally.
Abnormalfindingssuggestlesionorotherdisorder
involvingsensorycortexordisorderaffectingposterior
column.
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Assessment of point localization
Ability to sense and locate area being stimulated.
With patient’s eyes closed, touch an area;
then have patient point to where he or she was touched.
Test both sides and upper and lower extremities.
Normal response:Point localization intact.
A B N O R M A L F I N D I N G S
Abnormal findings suggest lesion or other disorder
involving sensory cortex or disorder affecting posterior
column.
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Neurological Examinations cont’d
Meningeal Signs
Classic signs of meningitis include
Nuchal rigidity (extension of neck stiffness), Kernig’s
sign and Brudzinski’ssigns.
To assess for Brudzinski’ssign
Have the patient lie supine with her or his head flexed to
her or his chest.
Flexion of the hips is a positive sign of meningitis.
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Neurological Examinations cont’d
To assess for Kernig’s sign :
have the patient lie supine with one leg flexed.
Tell him or her to try to extend the leg while you apply
pressure to the knee contraction and pain of the
hamstring muscles and resistance to extension are
positive signs of meningitis
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THE END!!!
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