Physical Examination


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Neurologic Examination

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Physical Examination

  1. 1.
  2. 2. • Posture, gait, coordination: perform Rhomberg test • Personal hygiene and grooming • Check speech/communication: • • • • Check speech: rapid, slow, halting Clarity: slurred or distinct Tone: high-pitched, rough Vocabulary: appropriate choice of words
  3. 3. Mental Status General appearance and behavior Level of consciousness • Oriented to person, place and time • Appropriate response to verbal and tactile stimuli • Memory, problem solving abilities. Mood Thought content & intellectual capacity
  4. 4. Pupils and EOM: Size of pupils should be equal Reaction of pupils • • • Accommodation: pupillary constriction to accommodate near vision Direct light reflex: constriction of pupil when light is shone directly into the eye Consensual reflex: constriction of the pupil in the opposite eye when the direct light reflex is tested. Evaluate EOM: • • • Note nystagmus Ability of eyes to move together Resting position of iris should be at mid-position of the eye socket
  5. 5.  Neurologic examination is an indirect evaluation that assesses the function of specific body part controlled f 5 COMPONENTS OF NEURO ASSESSMENT (1) Cerebral function (2) Cranial Nerves (3) Motor system (4) Sensory System (5) Reflexes
  6. 6. Cerebral abnormalities cause: - disturbance in mental status - Intellectual function - Thought content - Pattern of emotional behavior - Alteration in perception, motor and language ability - Lifestyle changes
  7. 7.  Should be specific and non-judgemental  Avoid using the terms “inappropriate” or “demented”  Specific records on observations regarding orientation, level of consciouness, emotional state or thought content
  8. 8.  patient’s appearance & behavior  dress, grooming & personal hygiene  Posture, gesture, movements, facial expression & motor activity  manner of speech & level of consciousness  orientation to time, place & person
  9. 9. Average IQ of a person can: - Recite 5 digits backwards - Serial 7’s (Subtract 7 from 100, then 7 from that, and so forth)  Interpret proverbs  Ability to recognize similarities  Situational analysis
  10. 10. Are the patient’s thought…      Spontaneous Natural Clear Relevant Coherent f - hallucinations, preoccupation with death and morbid events, paranoid ideation requires further evaluation
  11. 11.  Is the patient’s affect natural or even?  Does his or her mood fluctuate normally?  Are verbal communications consistent with nonverbal cues?
  12. 12.  Agnosia - inability to recognize objects seen through the special senses ◦ a patient may see a pencil but knows not what to do with it or what it’s called  Screening for visual and tactile agnosia provides insight into the patient’s cortical interpretation ability ◦ Placing a familiar object (key) in the patient’s hand, have him identify it with eyes closed
  13. 13.  normal neurologic function: understand and communicate in spoken and written language.  Aphasia is a deficiency in language function Type of Aphasia Brain area involved Auditory-receptive Temporal Lobe Visual-receptive Parietal-occipital lobe Expressive speaking Inferior posterior frontal areas Expressive writing Posterior frontal area
  14. 14.  Ask the patient to perform a skilled act (throw a ball, move a chair)  Performance requires - the ability to understand the activity desired and normal motor strength  Failure signals cerebral dysfunction
  15. 15. CRANIAL NERVES On Old Olympus Towering Tops A Finn And German Viewed Some Hops Olfactory (I) Optic (II) Occulamotor (III) Trochlear (IV) Trigemenal (V) Abducens (VI) Facial (VII) Acoustic (VIII) Glossopharyngeal (IX) Vagus (X) Spinal Accessory (XI) Hypoglossal (XII) M S M M M/S M M/S S M/S M/S M M
  16. 16. Before testing nerve function, ensure patency of each nostril by occluding in turn and asking patient to sniff  ask patient to close eyes  Occlude one nostril and hold aromatic substance (coffee) beneath nose  Ask patient to identify substance  Repeat with other nostril 
  17. 17. Normal: ■ Patient is able to identify substance. Abnormal: ■ Anosmia - loss of sense of smell.   inherited and non-pathological: chronic rhinitis, sinusitis, heavy smoking, zinc deficiency, or cocaine use. It may also indicate cranial nerve damage from facial fractures or head injuries, disorders of base of frontal lobe such as a tumor, or artherosclerotic changes .
  18. 18. Snellen chart to check/test: - distant vision - color Client should be 20 feet distant from the chart Use an object to occlude one eye Evaluate the vision one eye at a time
  19. 19. Test for ocular rotations, conjugate movements, nystagmus - Trochlear Nerve (IV): Pupillary Light Reflex and Ptosis using direct & consensual pupillary reaction to light
  20. 20. Abnormal: Normal: ■ Able to read without ■ CN II deficits difficulty ■ Visual acuity intact 20/20, both eyes Hippus phenomenon: Brisk constriction of pupils in reaction to light, followed by dilation and constriction - may be normal or sign of early CN III compression. - can occur with stroke or brain tumor. ■ Changes in pupillary reactions - can signal CN III deficits. ■ Increased ICP causes changes in pupillary reaction
  21. 21. a. Test motor function: - patient to move jaw from side to side against resistance and then clench jaw as you palpate contraction of temporal and masseter muscles, or to bite down on a tongue blade.
  22. 22. Testing sensory function: - patient to close eyes - Touch the face with the wisp of cotton - Instruct to tell you when he or she feels sensation on the face. - Repeat the test using sharp and dull stimuli (toothpick or tongue blade) - Instruct to say “Sharp” or “Dull”
  23. 23. Testing corneal reflex: - Gently touch cornea with cotton wisp. o Alternative approach is to: > puff air across cornea with a needless syringe > gently touch eyelash and look for blink reflex
  24. 24. Abnormal: Normal:  Full range of motion (ROM) in jaw and strength.  Patient perceives light touch and superficial pain bilaterally  Weak or absent contraction unilaterally: - Lesion of nerve, cervical spine, or brainstem  Inability to perceive light touch and superficial pain - may indicate peripheral nerve damage. ■ Trigeminal Neuralgia: - Neuralgic pain of CN V caused by the pressure of degeneration of a nerve ■ Corneal reflex test used in patients with decreased LOC - to evaluate integrity of brainstem.
  25. 25. a. Testing motor function: - patient to perform these movements: smile, frown, raise eyebrows, show upper teeth, show lower teeth, puff out cheeks, purse lips, close eyes tightly while trying to open them.
  26. 26. Testing sensory function: Test taste on ant two-thirds of tongue for sweet, sour, salty. Sweet: Tip of the tongue Sour: Sides of back half of tongue Salty: Anterior sides and tip of tongue Bitter: Back of tongue
  27. 27. Normal: Facial nerve intact Able to make faces. Taste sensation on anterior tongue intact Abnormal: Asymmetrical or impaired movement: Nerve damage, such as that caused by Bell’s palsy or stroke. Impaired taste/loss of taste: Damage to facial nerve, chemotherapy or radiation therapy to head and neck.
  28. 28.       Do Weber and Rinne tests for hearing watch-tick test by holding watch close to patient’s ear. Perform Rhomberg test for balance - Stay at the back / side of the pt. - Instruct: to stand straight, feet together, hands at the side and eyes closed. (Evaluates the balancing function of the CN VIII)
  29. 29. Normal:  Hearing intact.  Negative Rhomberg test. Abnormal:  Hearing loss, nystagmus, balance disturbance, dizziness/vertigo: - Acoustic nerve damage. ■ Nystagmus: - CN VIII, brainstem, or cerebellum problem or phenytoin toxicity.
  30. 30. a. Observe ability to cough, swallow, and talk. b. Test motor function: - patient to open mouth and say “ah” while you depress the tongue with a tongue blade. - Observe soft palate and uvula. - Soft palate and uvula should rise medially.
  31. 31. c. Test sensory function of CN IX and motor function of CN X by stimulating gag reflex.  Tell patient that you are going to touch interior throat  Then lightly touch tip of tongue blade to posterior pharyngeal wall.  Observe the pharyngeal movement.  Ask the client to drink a small amount of water - ease & difficulty of swallowing - quality of the voice or hoarseness when speaking
  32. 32. Normal:  Swallow and cough reflex intact.  Speech clear.  Elevation and constriction of pharyngeal musculature and tongue retraction (+) gag reflex Abnormal:  Unilateral movement: Contralateral nerve damage. - Damage to CNs IX and X also impairs swallowing. ■ Changes in voice quality (e.g., hoarseness): CN X damage. ■ Diminished/absent gag reflex: Nerve damage - Risk for aspiration ■ Impaired taste on posterior portion of tongue: Problem with CN IX
  33. 33. a. motor function of shoulder and neck muscles: - Ask patient to shrug shoulders upward against your resistance. (Trapezius muscle) - Then ask pt to turn head from side to side against your resistance. (Strenoclaidomastoid muscle)
  34. 34. Normal:  Movement symmetrical, with patient moving against resistance without pain. ■ Full ROM of neck with +5/5 strength. Abnormal:      Asymmetrical Diminished Absent movement Pain unilateral or bilateral weakness: Peripheral nerve CN XI damage.
  35. 35. a. Let patient say “d, l, n, t” or a phrase containing these letters. b. Ask the patient to protrude the tongue. Observe any deviation from midline, tumors, lesions, or atrophy. c. Now ask the patient to move the tongue from side to side.
  36. 36. Abnormal: Asymmetrical/diminished/ absent movement/deviation from midline/protruded tongue: - Peripheral nerve CN XII damage. ■ Tongue paralysis results in dysarthria. Normal:  Can protrude tongue medially.  No atrophy, tumors, or lesions.
  37. 37.  Assessing the patient’s ability to flex or extend the extremities against resistance tests muscle strength. g  The evaluation of muscle strength compares the sides of the body with each other  f This way, subtle differences in muscle strength can easily be detected and described.
  38. 38.   Muscle tone is evaluated by palpation Abnormalities in tone include: ◦ Spasticity (increased muscle tone) ◦ Rigidity (resistance to passive strength) ◦ Flaccidity
  39. 39.  Cerebellar influence on the motor system is reflected in balance and coordination.  Coordination of the hands and extremities is tested by: ◦ Rapid, alternating movements ◦ POINT TO POINT TESTING
  40. 40. Balance and Coordination a. Rapid Alternating Movements (RAM) Ask the person to pat the knees with both hands, lift up, turn hands over, and pat the knees with the backs of the hands. Then ask to do this faster. Abnormal: Lack of coordination Dysdiadochokinesia - Slow, clumsy, and sloppy response - occurs with cerebellar disease Normal:  done with equal turning and quick rhythmic pace
  41. 41. Finger-to-Finger test With the persons eyes open, ask that he or she use index finger to touch your finger, then his own nose. After a few times move your finger to a different spot. Abnormal: Dysmetria - clumsy movement with overshooting the mark - occurs with cerebellar disorder Past-pointing - constant deviation to one side Normal:  Movement is smooth and accurate
  42. 42.  Coordination in the lower extremities is tested: run heel down the anterior surface of the tibia of the other leg. Each leg is tested  Ataxia is incoordination of voluntary muscle groups in action  Tremors are rhythmic, involuntary movements =>The presence of these movements suggests cerebellar disease
  43. 43. Cerebellum: for balance and coordination. Rhomberg’s Test  screening test for balance  pt stands with feet together and arms at the side, first with eyes open and eyes closed for 20 to 30 seconds  sway is normal but loss of balance is abnormal and considered (+) Rhomberg Test
  44. 44. Abnormal: Sways, falls, widens base of feet to avoid falling Positive Rhomberg sign -Loss of balance that occurs when closing the eyes. -Occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication) -Loss of proprioception, and loss of vestibular function Normal: Negative Romberg test
  45. 45. Tandem Walking - ask the person to walk a straight line in a heel-to-toe fashion. - This decreases the base of support and will accentuate any problem with coordination. Normal: Person can walk straight & stay balanced Abnormal: Crooked line walk Widens base to maintain balance Staggering, reeling, loss of balance An ataxia that did not appear now. Inability to tandem walk is sensitive for an upper motor neuron lesion, such as multiple sclerosis.
  46. 46.     Motor reflex are involuntary contraction of muscles in response to abrupt stretching near the site of muscle insertion Technique: A reflex hammer is used to elicit a deep tendon reflex. The tendon is struck briskly, and the response is compared with the opposite side of the body (right and left) Response should be equal
  47. 47. GRADING : The absence of reflex is significant, although ankle jerks (achilles reflex) may be absent on older people.  Some uses the terms: ◦ PRESENT ◦ ABSENT ◦ DIMINISHED
  48. 48. Deep tendon reflex grades Deep tendon reflex grades 0 absent 0 absent + present but diminished + present but diminished + + normal + + normal + + + increased but not necessarily pathologic + + + increased but not necessarily pathologic + + + + hyperactive or clonic (involuntary contraction + + + + hyperactive or clonic (involuntary contraction and relaxation of skeletal muscle) and relaxation of skeletal muscle) Superficial reflex grades Superficial reflex grades 0 absent 0 absent + present + present
  49. 49. Biceps Reflex - is elicited by striking the biceps tendon of the flexed elbow. - the examiner supports the forearm with one arm while placing the thumb against the tendon and striking the thumb with the reflex hammer. Normal: ■ Flexion at the elbow and contraction of the biceps
  50. 50. b. Triceps Reflex - flex pt’s arm to 90° angle and positioned in front of the chest ■ Abduct patient’s arm and flex it at the elbow. ■ Support the arm with your non-dominant hand. ■ Identify triceps tendon by palpating 2.5 to 5cm (1-2 in) above the elbow Normal: ■ Contraction of triceps with extension at elbow
  51. 51. c. Patellar Reflex ■ Have patient sit with legs dangling. ■ Strike tendon directly below patella. Normal: ■ Contraction of quadriceps with extension of knee.
  52. 52. d. Ankle - Achilles reflex - foot is dorsiflexed at the ankle and the hammer strikes the stretched Achilles tendon Normal: ■ Plantar flexion of foot.
  53. 53. Test for Clonus • When reflexes are very hyperactive, a phenomenon called clonus may be elicited • If a foot is abruptly dorsiflexed, it may continue to “beat” two to three times before it settles into a position of rest • The presence of clonus always indicates the presence of CNS disease and requires further evaluation Normal: ■ No contraction
  54. 54. Superficial Reflexes Abdominal Reflex ■ Stroke patient’s abdomen diagonally from upper and lower quadrants toward umbilicus. ■ Contraction of rectus abdominis. Umbilicus moves toward stimulus.
  55. 55. Perianal Reflex ■ Gently stroke skin around anus with gloved finger. Normal: ■ Anus puckers. Cremasteric Reflex ■ Gently stroke inner aspect of a male’s thigh. Normal: ■ Testes rise. Bulbocavernosus Reflex ■ Gently apply pressure over bulbocavernous muscle on dorsal side of penis. Normal: ■ Bulbocavernosus muscle contracts.
  56. 56. BABINSKI REFLEX ■ Stroke sole of patient’s foot in an arc from lateral heel to medial ball. • • • Fanning of toes when stroked laterally Normal in newborn (found until 16 – 24 mos) Indicates CNS disease of motor system Normal: ■ Flexion of all toes.
  57. 57. The examiner should be familiar with dermatomes  Most sensory deficits results from peripheral neuropathy and follow anatomic dermatomes  Assessment involves:  Tactile sensation  Superficial pain  Vibration  Position sense ** pt eyes are kept closed
  58. 58. Tactile Sensation or Light Touch - Brush a light stimulus: cotton wisp over patient’s skin in several locations, including torso and extremities. Normal:  Identifies areas stimulated by light touch. Abnormal: Hypesthesia: diminished capacity for physical sensation (esp. skin) ■ Hyperesthesia: Increased sensitivity ■ Paresthesia: Numbness & tingling ■ Anesthesia: Loss of sensation.
  59. 59. PAIN and TEMPERATURE •Stimulate skin lightly with sharp and dull ends of toothpick/ paper clip •Apply stimuli randomly and ask patient to identify whether sensation is sharp or dull •Touch patient’s skin with test tubes filled with hot or cold water. •Apply stimuli randomly, and ask patient to identify whether sensation is hot or cold.
  60. 60. VIBRATION and PROPRIOCEPTION - 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. - If patient is unable to detect vibration, test proximal areas as well.
  61. 61. Normal:  Vibratory sensation intact bilaterally in upper and lower extremities. Abnormal:  Diminished/absent vibration sense: - Peripheral nerve damage caused by alcoholism, diabetes, or damage to posterior column of spinal cord.
  62. 62. Stereognosis Normal: Stereognosis intact bilaterally. Abnormal: ■ Abnormal findings suggest a lesion or other disorder involving sensory cortex or a disorder affecting posterior column.
  63. 63. Sensory Extinction ■ Simultaneously touch both sides of patient’s body at same point. ■ Ask patient to point to where she or he was touched. Normal: Abnormal:  Extinction intact. Identification of stimulus on only one side suggests lesion or other disorder involving sensory cortical region in opposite hemisphere.
  64. 64. Level of Consciousness : ♦Alert – fully awake; appropriate responses to external and internal stimuli; oriented to person, place and time s ♦Lethargic – somnolent, drowsy, listless, indifferent to surroundings, very sleepy, can be aroused from sleep but when stimulation ceases, falls back to sleep; may be oriented or confused d ♦Stuporous – unconscious most of the time but makes spontaneous movements and response is evoked only by a strong, continuous, noxious stimuli; loud noises or sounds, bright light, pressure to sternum, response is usually a purposeful attempt to remove the stimulus f ♦Comatose – absence of voluntary response to stimuli including painful stimuli; no response, no eye opening – score of 7 or less on GCS
  65. 65. Fully alert- 15, a score of 7 or less reflects coma. (Kozier p. 703-704)
  66. 66. Test orientation to time, place, and person Normal:  Awake, alert, and oriented to time, place, and person (AAO x 3)  Responds to external stimuli Abnormal:  Disorientation may be physical in origin  Disorientation can also be psychiatric in origin (schizophrenia)  Lathargic or somnolent  Obtunded  Stupor  Coma
  67. 67. Paralysis  Loss or impairment of the ability to move a body part, usually as a result of damage to its nerve supply.  Loss of sensation over a region of the body. Hemiplegia paralysis of one side of the body Paraplegia paralysis of both lower limbs due to spinal disease or injury Quadriplegia paralysis of all four limbs or of the entire body below the neck Paresis partial motor paralysis
  68. 68. Fasciculations Rapid, continuous twitching of resting muscle Tic Repetitive twitching of a muscle group Myoclonus Rapid, sudden jerk at a fairly regular intervals Tremor Involuntary contraction of opposing muscle groups Rest tremor Intention tremor
  69. 69. Chorea Sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face Athetosis Slow, twisting, writhing, continuous movement, resembling a snake or worm
  70. 70. Brudzinski’s sign - neck stiffness - involuntary flexion of hips and knees when flexing neck is positive sign for meningeal irritation
  71. 71. Positive Kernig’s sign -excessive pain in the lower back when examiner attempts to straighten knees with client supine and knees and hips flexed
  72. 72.