NEUROLOGICAL examination.ppt

neurological exam

1. NEUROLOGICAL
EXAMINATION

2. INTRODUCTION:
Aneurologicalexaminationisthe
motorassessmentofsensoryneuronand
responses,especiallyreflexes,todetermine
whetherthenervoussystemisimpaired.
Thistypicallyincludesaphysicalexamination
andareviewofthepatient'smedicalhistory
butnotdeeperinvestigationsuchas
neuroimaging.Itcanbeusedbothasa
screeningtoolandasaninvestigativetool.

3. ExamplesofDefinitions
•Alert:
awake,looksaboutrespondsinameaningfulmannerto
verbalinstructionsorgestures
•Drowsy:
orientedwhenawakebutifleftalonewillsleep
•Confused:
disorientedtotime,place,orpersonomemorydifficultyis
common
hasdifficultywithcommands
exhibitsalterationinperceptionofstimuli,maybeagitated

4. •Stuporous:
generallyunresponsiveexcepttovigorousstimulation
maymakeattemptatverbalizationtovigorous/repeated
stimuli
Openseyestodeeppain
•Comatose:
unarousableandunresponsivesomelocalizationor
movementmaybeacceptablewithinthecomatose
categorydependingonthecomadefinitionse.g.lightcoma
todeepcoma
Doesnotopeneyestodeeppain

5. ThedifferencebetweenComaandSleep:
•sleepingpersonsrespondtounaccustomedstimuli
•sleepingpersonsarecapableofmentalactivity
(dreams)
•sleepingpersonscanberousedtonormal
consciousness
•cerebraloxygenuptakedoesnotdecreaseduring
sleepasitoftendoesincoma

6. SpecialStatesofAlteredLevelsofConsciousness
•BrainDeath:
Anirreversiblelossofcorticalandbrainstemactivity.
•PersistentVegetativeState:
Aconditionthatfollowsseverecerebralinjuryinwhichthe
alteredstatebecomes
chronicorpersistent.
•Locked-inSyndrome:
Astateofmuscleparalysis,involvingvoluntarymuscles,
whilethereispreservationoffull
consciousnessandcognition.

7. Indications:
Aneurologicalexaminationisindicated
wheneveraphysiciansuspectsthatapatient
mayhaveaneurologicaldisorder.Any
newsymptomofanyneurologicalorder
maybeanindicationforperforminga
neurologicalexamination.

8. ORGANICDISEASE?
Signs&/orsymptomsthatcannotbefakedmust
beexaminedclosely.
Examplesinclude,asymmetryinpupils,
abnormalretinalexams,nystagmus,muscle
atrophy,andmusclefasciculation.

9. UpperMotorNeurons(UMN)aredefinedasthe
connectionsofmotornervesbeforetheyleave
thespinalcord
LowerMotorNeurons(LMN)aredefinedas
afterthesynapse(connection)intothe
peripheralnervecellbodies.

10. Objectives
 OrganizeExamintothe6Subsetsof
Function
 ConceptofScreeningExamination
 UnderstandAfferentandEfferent
PathwaysforBrainstemReflexes
 DifferentiateBetweenUpperandLower
MotorNeuronFindings

11. SixSubsetsoftheNeuroExam
Here’swhat youneed to examine.
MentalStatus
CranialNerves
Motor
Sensory
Coordination
Reflexes

12. ConceptofaScreeningExam
Screeningeachofthesubsetsallowsonetocheck
ontheentireneuroaxis(Cortex,SubcorticalWhite
Matter,Basal
Ganglia/Thalamus,Brainstem,Cerebellum,Spinal
Cord,PeripheralNerves,NMJ,andMuscles)
Expandevaluationofagivensubsettoeither
•AnswerquestionsgeneratedfromtheHistory
•Confirmorrefuteexpectedorunexpectedfindings

13. NeurologicalExamination
MentalStatusExam
“FOGS”
Familystoryofmemoryloss
Orientation
GeneralInformation
Spelling&/ornumbers
Recognitionofobjects

14. 1.INTERVIEW
Thepatient/familyinterviewwillallowto:
•ƒgatherdata:bothsubjectiveandobjectiveaboutthe
patient'sprevious/presenthealthstate
•ƒprovideinformationtopatient/family
•ƒclarifyinformation
•ƒmakeappropriatereferrals
•ƒdevelopagoodworkingrelationshipwithboththepatient
andthefamily
•ƒinitiatethedevelopmentofawrittenplanofcarewhichis
patientspecific

15. Interviewtoidentifypresenceof:
•headache
•difficultywithspeech
•inabilityto reador write
•alterationinmemory
•alteredconsciousness
•confusionor changeinthinking
•disorientation
•decreaseinsensation,tinglingor pain
•motor weaknessor decreasedstrength
•decreasedsenseof smellor taste
•changeinvisionor diplopia
•difficultywithswallowing
•decreasedhearing
•alteredgaitor balance
•dizziness
•tremors, twitchesor increasedtone

16. PhysicalExaminationConsiderations
•Level of Consciousness
–Mostimportantaspectofneurologicexamination
–Levelofconsciousnessfirsttodeteriorate;changes
oftensubtle,thereforerequiringcarefulmonitoring.
•Consciousness:
–ComposedofTwoComponents:
•Arousal(Alertness)
•Awareness(Content)
–Assessment:Orientationvs.Disorientation
»Person,Place&Time
»Varyingsequenceofquestionsisimportant!!

17. AssessingLOC
•GlasgowComaScale(GCS)
–ThreeCategories:
•Eyeopening
•Bestmotorresponse
•Bestverbalresponse
–Scoring
•Highestorbestpossiblescore15
•Ascoreof<8indicatescoma
•Lowestorworstpossiblescore3

18. GlasgowComaScale

19. PupillaryExamination
•Thepupillaryexaminationcanbequicklyandeasily
performedintheunconsciousorminimallyresponsive
patientwhenaTBIissuspected,andcanprovidevaluable
informationaboutthedegreeofinitialorprogressingbrain
injury.SeveraltypesofTBI’smaycausepupillary
changes,whichindicatetheneedforrapidinterventionsto
decreaseICPcausedbycerebralbleedingand/oredema.
Nursesareinakeypositiontodetectearlychangesina
patient'sconditionandadministeroradvocatefor
immediateinterventions.

20. Checkpupilsizeinlightedroom,and
reactivitytolightinadarkenedroom.

21. Unequal
pupilsize
canbeasign
ofaserious
braininjury.

22. Brain
Injurywith
bleeding
orswelling
Rapidinterventions
areneededtoprevent
deathorpermanent
braindamage–TBI’s
canprogressrapidly!

23. MentalStatus
LevelofAlertness
•SubjectiveviewofExaminer
•DefinitionofConsciousness
•TerminologyforDepressedLevelofConsciousness
•ConceptofComa
•Delerium
DegreeofOrientation
•Towhat?

24. MentalStatus
Concentration
•Serial 7’s or 3’s
•“WORLD” backwards
•MonthsoftheYearBackwards
•Trytoquantifydegreeofimpairment
*AandOandConcentrationneedtobeintactforother
aspectsoftheMentalStatusExamtohavelocalizing
value!

25. MentalStatus
Memory
ImmediateRecall
•Ataskofconcentration
Short-TermMemory
•“3/3objectsafter5minutes”
Long-TermMemory
•Lastthingtogo

26. Mental Status
Language
AphasiavsDysarthria
ReceptiveLanguage
•CommandFollowing
ExpressiveLanguage
•Fluency
•WordFinding
Repetition
•ScreensforReceptive,Expressive,andConductive
Aphasias

27. Language

28. MentalStatus
Calculations,R-Lconfusion,fingeragnosia,
agraphia
•Gerstmann’s Syndrome(DominantParietalLobe)
Hemineglect
•Non-DominantParietalLobe
DelusionalThinking,AbstractReasoning,Mood,
Judgement,FundofKnowledge,etc
•ImportantforPsychiatry
•Doesnotlocalizewelltooneregionofthecortex
•NeurocognitiveTestingrequiredtogetatmorespecific
deficits

29. OLFACTORYNERVE-I

30. OLFACTORY
NERVE
DistinguishCoffeefrom
Cinnamon
SmellingSaltsirritate
nasalmucosaandtestV2
TrigemminalSense
DisordersofSmellresult
fromclosedheadinjuries

31. OPTIC
NERVE
CRANIAL
NERVEII

32. OpticNerve
VisualAcuity
VisualFields
AfferentinputtoPupillaryLight
Reflex
•APD
LookattheNerve
(FundoscopicExam)
“VA equals 20/20 OU at near”
“PERRLA”

33. Oculomotor Nerve
Cn III
Trochlear Nerve
c.n. IV
Abducens Nerve
Cn VI

34. CNIIIOculomotor:moves
eyesinalldirectionsexcept
outwardanddown&in;
openseyelid;constrictspupil
CNIVTrochlear:
moveseyes
downandin…..

35. CNVIAbducens:moveseyesoutward
EOM’s:
(extraoccularmovement)
assessmentofeye
movementinall
directions(III,IV
VI)

36. TRIGEMINALNERVE-V

37. CNVTrigeminal:
3branches;sensationtothe
face,corneaandscalp;
opensjawagainst
resistance

38. FACIALNERVE-VII

39. CN VII
Facial:moves
theface;taste.
CNVIIparalysis

40. VESTIBULOCOCHLEAR
NERVE-VIII

41. VestibulocochlearNerve
HearingandBalance
•Patientswillcomplainoftinnitis,hearingloss,and/orvertigo
WeberandReneeTest
•DifferentiatesConductivevsSensorineuralhearingloss
AfferentinputtotheOculocephalicReflex
•Doll’sEyeManeuver
•ColdCalorics

42. GlossopharyngealandVagusNerves
c.n.’sIXandX

43. CNIXGlossopharyngeal:
movesthepharynx
(swallow,speech&gag)
CNXVagus:
voicequality

44. SpinalAccessoryNerve
c.n.XI
Trapezius
strength
Sternocleido-
Mastoid
strength

45. CNXISPİNAL ACCESSORY:
TURNSHEADANDELEVATESSHOULDERS
Shoulder
Shrug

46. HypoglossalNerve
c.n.XII

47. Hypoglossal Nerve
Protrudesthetongue
totheoppositeside
Tongueincheek
(strength)Hemi-atrophyand
fasiculations(LMN)

48. Strength
Tone
DTR’s
PlantarResponses
InvoluntaryMovements

49. Strength
MedicalResearchCouncilScale
5/5=FullStrength
4/5=WeaknesswithResistance
3/5=CanOvercomeGravityOnly
2/5=CanMoveLimbwithoutGravity
1/5=CanActivateMusclewithoutLimb
0/5=CannotActivateMuscle

50. WEAKNESS
DescribetheDistributionofWeakness
•UpperMotorNeuronPattern
•PeripheralneuropathyPattern
•MyopathicPattern

52. TONE
Toneistheresistanceappreciatedwhenmovinga
limbpassively
“Normal Tone”
Hypotonia
•“Central Hypotonia”
•“Peripheral Hypotonia”
IncreasedTone
•Spasticity(corticospinal)
•Rigidity (Basal Ganglia, Parkinson’s Disease)
•Dystonia(BasalGanglia)

53. DTR’s
0/4=Absent
1-2/4=NormalRange
3/4=PathologicallyBrisk
4/4=Clonus

54. InvoluntaryMovements
HyperkineticMovements
•Chorea
•Athetosis
•Tics
•Myoclonus
BradykineticMovements
•Parkinsonism(Bradykinesia,Rigidity,
PosturalInstability,RestingTremor)
•Dystonia

55. DriftAssessment
DriftAssessment:testformotor
weakness
Arm:holdarmsoutwithpalmsup;eyesclosed
•Pronator drift:handspronate(rollover);
•Motor drift:arm “drifts” downward
•Cerebellar drift: arm “drifts” back
towardheadorouttoside
Leg:noneedtocloseeyesmotor:leg
“drifts”toward bed

56. MovementAssessment
Movementsarepurposefulornon-purposeful
tubingsorbedlinens,scratchingnose
localizing:movingtowardorremovingapainfulstimulus;mustcross
themidline;occursinthecortex
withdrawal:pullingawayfrompain;occursinthehypothalamus
purposeful:pickingat
non-purposeful:donotcrossthemidline
abnormalflexion:(decorticate)rigidly
flexedarmsandwrists;fistedhands;occurs
inupperbrainstemabnormalextension:
(decerebrate)rigidly,rotatedinward
extendedarmswithflexedwristsandfisted
hands;occursinmidbrainorpons.
Decorticate
Decerebrate

58. LightTouch(MultiplePathways)
Pain/TemperatureSensation(SpinothalamicTract)
Vibration/PositionSensation(PosteriorColumns)
CorticalSensoryModalities
Stereognosis
Graphesthesia
Two-PointDiscrimination
DoubleSimultaneousExtinction
PrimarySensoryModalities

59. PainandTemperature
•Pinprick(Onepinperpatient!)
•SensationofCold
•LookforSensoryNerveor
DermatomalDistribution
VibrationSensation
•C-128HzTuningFork(checkgreat
toe)
JointPositionSensation
•Checkgreattoe
•RombergSign

60. HigherCorticalSensoryFunction
Graphesthesia
Stereognosis
Two-PointDiscrimination
DoubleSimultaneousExtinction
Gerstmann’s Syndrome (acalculia, right-left
confusion,fingeragnosia,agraphia)
•UsuallyseeninDominantParietalLobelesions

61. HEMISPHERE
DYSFUNCTION
DysmetriaonFinger-Nose-FingerTesting*
Irregularly-IrregularTappingRhythm*
Dysdiadochokinesis*
ImpairedCheck*
Hypotonia*
ImpairedHeel-Knee-Shin*
FallstoSideofLesion*
Nystagmus(VariableDirections)
*AllDeficitsareIpsilateraltothesideofthelesion

62. MIDLINEDYSFUNCTION
TruncalAtaxia
Titubation
AtaxicSpeech
GaitAtaxia
•AcuteAtaxia(unsteadyGait)
•ChronicAtaxia(wide-based,steadyGait)

63. REFLEXES

64. MUSCLESTRETCHREFLEXES(DEEP
TENDONREFLEXES)
•GRADED0-5
–0-ABSENT
–1-PRESENTWITHREINFORCEMENT
–2-NORMAL
–3-ENHANCED
–4-UNSUSTAINEDCLONUS
–5-SUSTAINEDCLONUS

65. MSR/DTR
•BICEPS
•BRACHIORADIALIS
•TRICEPS
•KNEE
•ANKLE

66. OTHERREFLEXES
•Uppermotorneurondysfunction
–BABINSKI
•presentorabsent
•toesdowngoing/flexorplantarresponse
–HOFMAN’S
–JAWJERK
•Frontalreleasesigns
–GRASP
–SNOUT
–SUCK
–PALMOMENTAL

67. AbmornalReflexes
AbnormalReflexes:
Babinski:initialinflectionofgreattoeinresponse
strokingofsole;upgoingtoeisabnormal
Grasp:involuntarygraspinresponsetostimulationofpalm;abnormalin
anadult
Doll’seyes:impairmentofeyemovementtooppositesidewhenhead
isturned=damagetobrainstem;nomovement=lossof
brainstem

68. NeuroAessessmentQuiz
•1.PeripheralNervousSystem(PNS)
ismadeupofthefollowingexcept::
a)Cranialnerves(12)
b)Ventricles
c)AxonsandNeurons
d)Spinalnerves(31)
e)Cerrebellarnerves
•2.TheAutonomicNervousSystem
containsboththeSympathetic
Divisionofnervesandthe
ParasympatheticDivisionofnerves.
TrueorFalse_.
•3.IntracranialHemorrhagecan
occurinthefollowingplacesexcept:
a)Epiduralspace
b)Subduralspace
c)Subarachnoidspace
d)Ethmoidspace
•.4.ACoupContracoupinjuryisdefined
as:Whentheheadstrikesafixed
object,thecoupinjuryoccursatthesiteof
impactandthecontrecoupinjuryoccurs
attheoppositeside.Trueor
False_
•5.TheFacialnervecontrols:
a)Movementofthechin,tongueandparotid
glands.
b)Movementofthetongue,softpaleteand
eyebrows.
c)Movementofthechinandcheeks
muscles.
d)Movementofallthefacialexpression
muscles.
•6.Whichnervecontrolsmovementonthe
neckandshoulders?
a)Abducens
b)Accoustic
c)SpinalAssesory
d)Occulomotor

69. •7.Aseriousinjurytothecervicalspine
andspinalcordmostlikelywillresultin
thefollowingcondition:
a)Hemiplegia
b)Quadraplegia
c)Paraplegia
d)Contralateralparalysis
•8.Anysuspectedhead,neckorspine
injuredvictimshouldimmediatelybe
givenspinalimmobilizationprecautions,
except:
a)Whenthevictimcomplainsofpainonly
uponturninghisheadtooneside.
b)Whenthevictimrefusestoallowspinal
immobilizationevenafterlistening
carefullytomultipleattemptstoexplain
thedangersandriskinvolved.
c)Whenthevictimisintoxicatedon
alcoholandcannotspeakclearly.
d)Whenthevictimwasneverunconscious
anddeniesanypain.
•9.Whenassessingapatientwithaltered
LOC,youfeelhisstateofawareness/arousalis
best described as “Obtunded”, this means:
a)Verydrowsy,whennotstimulated,butcan
followsimplecommandswhenstimulated(i.e.
shakingorshouting);verbalresponsesinclude
oneortwowords,butwilldriftbacktosleep
withoutstimulation.
b)Astateofdrowsiness;clientneedsincreased
externalstimulitobeawakenedbut,remains
easilyarousable;verbal,mental&motor
responsesaresloworsluggish.
c)Awakensonlytovigorousandcontinuous
noxious(painful)stimulation;minimal
spontaneousmovement;motorresponsesto
painareappropriatebut,verbalresponsesare
minimalandincomprehensible(i.e.moaning).
d)Vigorousexternalstimulationfailstoproduce
anyverbalresponse;botharousaland
awarenessarelacking;nospontaneous
movementsbut,motorresponsestonoxious
stimulimaybebepurposeful

70. •10.TheGlasgowComascaletestsfor
threekindsofresponses,theyare:
a)EyeOpening
b)MotorResponse
c)VerbalResponse
d)AuditoryResponse
•11.Thebestandworstpossiblescoreon
theGCSis:
a)15and0
b)13and3
c)15and3
d)18and5
•12.Whenassessingpupillaryresponse,
youarelookingforthefollowing
conditionsexcept:
a)Coordinatedeyemovementandbilateral
blinking.
b)Reactivitytoandaccommodationto
light.
c)Symmetryofpupilsandaccommodation
tolight.
d)Abnormalpupilshape.
•13. A constricted “pin point” pupil indicates:
(bestanswer)
a)BrainStemherniation
b)CardiacArrest
c)CerebralInfarctionoftheparietallobe
d)CerebralInfarctionoftheoccipitallobe
e)Awidevarietyofconditions,somebeing
extremelylifethreatening.
•14.WhatCranialnerve(s)controlsthe
movementoftheeyesdownandin?
a)CNVIAbducens
b)CNIIIOculomotor
c)CNIVTrochleard)
•CNIIOptic
15.TheMotorstrengthscalegoesfrom0/5to
5/5,0beingnostrengthatalland5being
normalstrength.Apersonwithamotor
strengthof4/5wouldbe:
a)overcomesgravity;offersnoresistance
b)strongagainstresistance
c)weakagainstresistance
d)nomusclemovement

71. •16.Matchthefollowingpostureswith
itsdefinition:
•Decerebrate_
•Decorticate_
a)Abnormalflexion:rigidlyflexedarmsand
wrists;fistedhands;occursinupper
brainstem
b)Abnormalextension:rigidly,rotated
inward,extendedarmswithflexedwrists
andfistedhands;occursinmidbrainor
pons.
•17.TheBabinskireflexistheinitial
inflection(extension)ofgreattoein
responsestrokingofthesoleofthefoot,
selectthecorrectanswer:
a)Anupgoinggreattoeisabnormal.
b)Anupgoinggreattoeisnormal.
c)Anupgoinggreattoeisabnornalin
adults.
d)Anupgoinggreattoeisnormalin
infants.
•Answers
•1 e
•2 True
•3 d
•4 True
•5d
•6 c
•7 b
•8 b
•9 a
•10d
•11c
•12a
•13e
•14c
•15c
•16Decer=b.Decor=a
•17c&d