neurologic assesment

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assessing the neurologic status, including cranial nerves assessment. DTR (deep tendon reflexes)

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neurologic assesment

  1. 1. Neurologic Assessment Maria Carmela L. Domocmat, RN, MSN Instructor, Nursing Health Assessment School of Nursing Northern Luzon Adventist College
  2. 2. Nervous System Anatomy: Review6/26/2011 2 Maria Carmela L. Domocmat, RN, MSN
  3. 3. http://sciencecity.oupchina.com.hk/biology/student/glossary/img/peripheral_nervous_system.jpg 6/26/2011 3 Maria Carmela L. Domocmat, RN, MSN
  4. 4. 6/26/2011 4 Maria Carmela L. Domocmat, RN, MSN
  5. 5. 6/26/2011 5 Maria Carmela L. Domocmat, RN, MSN
  6. 6. 6/26/2011 6 Maria Carmela L. Domocmat, RN, MSN
  7. 7. The right cerebral hemisphere controls movement of the left side of the body.6/26/2011 7 Maria Carmela L. Domocmat, RN, MSN
  8. 8. 6/26/2011 8 Maria Carmela L. Domocmat, RN, MSN
  9. 9. The cerebellum processes input from other areas of the brain, spinal cord and sensory receptors to provide precise timing for coordinated, smooth movements of the skeletal muscular system. A stroke affecting the cerebellum may cause dizziness, nausea, balance and coordination problems. http://health.allrefer.com/pictures-images/cerebellum-function.html6/26/2011 9 Maria Carmela L. Domocmat, RN, MSN
  10. 10. 6/26/2011 10 Maria Carmela L. Domocmat, RN, MSN
  11. 11. 6/26/2011 11 Maria Carmela L. Domocmat, RN, MSN
  12. 12. Neurologic Assessment: OVERVIEW
  13. 13. Neurologic System Assessment Organized into 5 major areas: 1. Mental Status 2. Cranial Nerves 3. Sensory System 4. Motor System & Cerebellar 5. Reflexes6/26/2011 13 Maria Carmela L. Domocmat, RN, MSN
  14. 14. Mental Status and Level of Consciousness Observe the following: • LOC • posture and body movements • dress, grooming and hygiene • facial expression • speech • mood, feelings, and expressions • thought processes and perceptions • cognitive abilities6/26/2011 14 Maria Carmela L. Domocmat, RN, MSN
  15. 15. Cranial Nerves• I (olfactory)• II (optic)• III (oculomotor), IV (trochlear), VI (abducens)• V (trigeminal)• VII (facial)• VIII acoustic/vestibulocochlear)• IX (glossopharyngeal), X (vagus)• XI (spinal accessory)• XII (hypoglossal)6/26/2011 15 Maria Carmela L. Domocmat, RN, MSN
  16. 16. Motor and cerebellar systems assess condition and movement of muscles evaluate balance assess coordination6/26/2011 16 Maria Carmela L. Domocmat, RN, MSN
  17. 17. Sensory Systems• assess light touch, pain, and temperature sensations• test vibratory sensations• sensitivity to position• tactile discrimination (fine touch)6/26/2011 17 Maria Carmela L. Domocmat, RN, MSN
  18. 18. Reflexes • deep tendon reflexes • superficial o biceps reflexes o brachioradialis o plantar o triceps o abdominal reflex o patellar o cremasteric • Achilles reflex6/26/2011 18 Maria Carmela L. Domocmat, RN, MSN
  19. 19. Tests for meningeal irritation or inflammation• Neck mobility• Brudzinski’s sign• Kernig’s sign6/26/2011 19 Maria Carmela L. Domocmat, RN, MSN
  20. 20. MENTAL STATUS AND LEVEL OF CONSCIOUSNESS6/26/2011 20 Maria Carmela L. Domocmat, RN, MSN
  21. 21. Observe the following • LOC • posture and body movements • dress, grooming and hygiene • facial expression • speech • mood, feelings, and expressions • thought processes and perceptions • cognitive abilities6/26/2011 21 Maria Carmela L. Domocmat, RN, MSN
  22. 22. 6/26/2011 22 Maria Carmela L. Domocmat, RN, MSN
  23. 23. 6/26/2011 23 Maria Carmela L. Domocmat, RN, MSN
  24. 24. • Decorticate posture is • Decerebrate posture is an an abnormal posturing that abnormal body posture that involves involves• rigidity, flexion of the arms, • arms and legs being held• clenched fists, straight out,• extended legs (held out • toes being pointed straight). downward,• arms are bent inward toward • head and neck being arched the body backwards.• wrists and fingers bent and • muscles are tightened and held on the chest. held rigidly. http://www.nlm.nih.gov/medlineplus/ency/article/003300.htm6/26/2011 24 Maria Carmela L. Domocmat, RN, MSN
  25. 25. 6/26/2011 http://drugster.info/img/ail/938_943_1.png 25 Maria Carmela L. Domocmat, RN, MSN
  26. 26. 6/26/2011 http://loyaldavis.com/images/dec_1.jpg 26 Maria Carmela L. Domocmat, RN, MSN
  27. 27. For children under 5, the verbal response criteria are adjusted as followSCORE 2 to 5 YRS 0 TO 23 Mos. 5 Appropriate words or phrases Smiles or coos appropriately 4 Inappropriate words Cries and consolable Persistent inappropriate crying 3 Persistent cries and/or screams &/or screaming 2 Grunts Grunts or is agitated or restless 1 No response No response http://www.unc.edu/~rowlett/units/scales/glasgow.htm6/26/2011 27 Maria Carmela L. Domocmat, RN, MSN
  28. 28. CRANIAL NERVES6/26/2011 28 Maria Carmela L. Domocmat, RN, MSN
  29. 29. I (olfactory)o abnormal finding: inability to smell : neurogenic anosmia, olfactory tract lesion, tumor or lesion of frontal lobe loss of smell: congenital, nasal dse, smoking, use of cocaine6/26/2011 29 Maria Carmela L. Domocmat, RN, MSN
  30. 30. CN II (optic)o visual acuity – both far and nearo confrontation testo asses retina using ophthalmoscopeo OD – R eye; OS – L eye; OU - both eyes6/26/2011 30 Maria Carmela L. Domocmat, RN, MSN
  31. 31. CN II (optic)o normal finding: round red reflex optic disc – 1.5 mm; round or slightly oval; well- defined margins,creamy pink paler physiologic cup retina – pink6/26/2011 31 Maria Carmela L. Domocmat, RN, MSN
  32. 32. CN II (optic)o abnormal finding: blurred optic disc margins; dilated, pulsating veins - Papilledema (swelling of optic nerve) – due to increased ICP from tumor or hemorrhage optic atrophy – brain tumors6/26/2011 32 Maria Carmela L. Domocmat, RN, MSN
  33. 33. III (oculomotor), IV (trochlear), VI (abducens)o (a) inspect margin of eyelidso (b) extraocular muscleso (c) pupillary response to light6/26/2011 33 Maria Carmela L. Domocmat, RN, MSN
  34. 34. CN III, IV, VIo normal finding: (a) eyelid covers abt 2 mm of iris (b) eyes move smooth, coordinated motion in all directions (c) bilateral constriction6/26/2011 34 Maria Carmela L. Domocmat, RN, MSN
  35. 35. CN III, IV, VIo abnormal finding: (a) ptosis (drooping of eyelids) – myasthenia gravis (b) abnormal eye movements • nystagmus (rhythmic oscillation of the eyes) - cerebellar disorder • limited eye movement – increased ICP • paralytic strabismus – paralysis of oculomotor, trochlear or abducens nerves6/26/2011 35 Maria Carmela L. Domocmat, RN, MSN
  36. 36. Nystagmus video6/26/2011 Maria Carmela L. Domocmat, RN, MSN 36
  37. 37. CN III, IV, VI (c) dilated pupil (6-7 mm) – oculomotor nerve paralysis Argyll Robertson pupils – CNS syphilis, meningitis, brain tumor, alcoholism6/26/2011 37 Maria Carmela L. Domocmat, RN, MSN
  38. 38. Argyll Robertson pupils6/26/2011 38 Maria Carmela L. Domocmat, RN, MSN
  39. 39. CN III, IV, VI constricted, fixed pupils – narcotics abuse, damage to pons unilaterally dilated pupil unresponsive to light or accommodation – damage to CN III constricted pupil unresponsive to light or accommodation – lesions of the SNS (sympathetic nervous sys)6/26/2011 39 Maria Carmela L. Domocmat, RN, MSN
  40. 40. CN V (trigeminal) o motor function o sensory function :6/26/2011 40 Maria Carmela L. Domocmat, RN, MSN
  41. 41. CN V (trigeminal) o motor function temporal and master muscles contraction (Note: may be difficult to perform and evaluate in client without teeth)6/26/2011 41 Maria Carmela L. Domocmat, RN, MSN
  42. 42. CN V (trigeminal) o sensory function : sharp or dull sensation and light touch on forehead, chin and cheeks • safety pin, paper clip, or cut tongue depressor; wisp of cotton corneal reflex (blinking reflex) (Note: may be absent or reduced in clients who wear contact lenses)6/26/2011 42 Maria Carmela L. Domocmat, RN, MSN
  43. 43. Corneal refle6/26/2011 43 Maria Carmela L. Domocmat, RN, MSN
  44. 44. CN Vo normal finding: temporal and masseter muscles contract bilaterally correctly identifies sharp or dull, light touch6/26/2011 44 Maria Carmela L. Domocmat, RN, MSN
  45. 45. CN Vo abnormal finding: inability to identify – lesions in trigeminal nerve, lesions in spinothalamic tract or posterior columns absent corneal reflex – lesions of CN V, lesions of motor part of CN VII6/26/2011 45 Maria Carmela L. Domocmat, RN, MSN
  46. 46. CN VII (facial)o motor functiono sensory function6/26/2011 46 Maria Carmela L. Domocmat, RN, MSN
  47. 47. CN VII (facial)o motor function smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise eyebrows, close eyes tightly against resistance6/26/2011 47 Maria Carmela L. Domocmat, RN, MSN
  48. 48. CN VII (facial)o sensory function taste test – anterior 2/3 of tongue – salt, sugar, or lemon juice6/26/2011 48 Maria Carmela L. Domocmat, RN, MSN
  49. 49. CN VIIo abnormal finding: inability to close eyes, wrinkle forehead, or raise forehead along with paralysis of lower part of face on affected side – Bell’s palsy (peripheral injury to CN VII) paralysis of lower part of face on opposite side affected - central lesions that affects the upper motor neurons ex: CVA6/26/2011 49 Maria Carmela L. Domocmat, RN, MSN
  50. 50. Bell’s palsy6/26/2011 Maria Carmela L. Domocmat, RN, MSN 50
  51. 51. CN VIII acoustic/vestibulocochlear)o hearing: acoustic/ cochlear Whisper, Weber, Rinne tests balance: vestibular6/26/2011 51 Maria Carmela L. Domocmat, RN, MSN
  52. 52. CN VIIIo abnormal finding: vibratory sound lateralizes to good ear – sensorineural loss AC is greater than BC but not twice as long6/26/2011 52 Maria Carmela L. Domocmat, RN, MSN
  53. 53. CN IX (glossopharyngeal), CN X (Vagus) uvula and soft palate gag reflex ability to swallow6/26/2011 53 Maria Carmela L. Domocmat, RN, MSN
  54. 54. CN IX & Xo abnormal finding: soft palate does not rise – bilateral lesion of CN X unilateral rising of soft palate, deviation of uvula to normal side –unilateral lesion CN X dysphagia or hoarseness – lesion CN IX or X6/26/2011 54 Maria Carmela L. Domocmat, RN, MSN
  55. 55. CN XI (spinal accessory)o trapezius muscle - shrug shoulders against resistanceo sternocleidomuscle – turn head against resistance6/26/2011 55 Maria Carmela L. Domocmat, RN, MSN
  56. 56. CN XIo abnormal finding: asymmetric, drooping of shoulders – paralysis or muscle weakness due to neck injury or torticollis atrophy with fasciculations – peripheral nerve dse6/26/2011 56 Maria Carmela L. Domocmat, RN, MSN
  57. 57. Torticollis6/26/2011 57 Maria Carmela L. Domocmat, RN, MSN
  58. 58. Atrophy with fasciculations6/26/2011 58 Maria Carmela L. Domocmat, RN, MSN
  59. 59. CN XII (hypoglossal)o strength and mobility tongueo protrude tongue, move to side against resistance, put back in mouth6/26/2011 59 Maria Carmela L. Domocmat, RN, MSN
  60. 60. CN XIIo normal finding: symmetric and smooth, bilateral strengtho abnormal finding: atrophy with fasciculations – peripheral nerve dse deviation to affected side – unilateral lesion6/26/2011 60 Maria Carmela L. Domocmat, RN, MSN
  61. 61. MOTOR AND CEREBELLAR SYSTEMS6/26/2011 61 Maria Carmela L. Domocmat, RN, MSN
  62. 62. Condition and movement of muscles o size and symmetry muscle grps o strength and tone o note unusual involuntary movement (i.e, fasciculations, tics, tremors)6/26/2011 62 Maria Carmela L. Domocmat, RN, MSN
  63. 63. o normal finding muscles- fully developed symmetric size (bilateral sides may vary 1 cm from each other) relaxed muscles contract voluntarily; show mild, smooth resistance to passive movement equally strong against resistance, without flaccidity, spasticity, rigidity no fasciculations, tics, tremors elderly –hand tremor or dyskinesia (repetitive movements of lips, jaw, tongue)6/26/2011 63 Maria Carmela L. Domocmat, RN, MSN
  64. 64. o abnormal finding muscle atrophy – dses of lower motor neurons or muscle disorders soft, limp, flaccid muscles fasciculations - muscle twitching tics – twitch of face, head or shoulders – stress, neurologic disorder tremors – rhythmic, oscillating movements – Parkinson’s dse, cerebellar dse, multiple sclerosis (with movement), hyperthyroidism, anxiety6/26/2011 64 Maria Carmela L. Domocmat, RN, MSN
  65. 65. Fasciculations6/26/2011 Maria Carmela L. Domocmat, RN, MSN 65
  66. 66. Tics6/26/2011 Maria Carmela L. Domocmat, RN, MSN 66
  67. 67. Tremors6/26/2011 Maria Carmela L. Domocmat, RN, MSN 67
  68. 68. o abnormal finding unusual bizarre face, tongue, jaw, lip movements – chronic psychosis, long term use of psychotropic drugs slow, twisting movements in extremities and face – cerebral palsy brief, rapid, irregular, jerky movements (at rest) - Huntington’s chorea6/26/2011 68 Maria Carmela L. Domocmat, RN, MSN
  69. 69. Balance, Gaito walk normallyo tandem walk – heel-to-toe walko romberg testo hop with one footo elderly – may be difficult to perform6/26/2011 69 Maria Carmela L. Domocmat, RN, MSN
  70. 70. o normal finding: steady gait, opposite arms swing maintains balance with little difficulty elderly – may be very difficult (-) Romberg test - erect with minimal swaying hops without losing balance6/26/2011 70 Maria Carmela L. Domocmat, RN, MSN
  71. 71. o abnormal finding (+) Romberg test – swaying, moving feet apart to prevent fall – dse of posterior columns, vestibular dysfunction, cerebellar disorders6/26/2011 71 Maria Carmela L. Domocmat, RN, MSN
  72. 72. Coordination Point-to-point Rapid Alternating Movements (RAM)6/26/2011 72 Maria Carmela L. Domocmat, RN, MSN
  73. 73. o Point-to-point finger-to-nose test Finger- nose- to-finger heel-to-shin test Note: dominant side may be more coordinated than nondominant side6/26/2011 73 Maria Carmela L. Domocmat, RN, MSN
  74. 74. 6/26/2011 74 Maria Carmela L. Domocmat, RN, MSN
  75. 75. 6/26/2011 75 Maria Carmela L. Domocmat, RN, MSN
  76. 76. http://cloud.med.nyu.edu/modules/pub/neurosurgery/coordination.html6/26/2011 76 Maria Carmela L. Domocmat, RN, MSN
  77. 77. Rapid Alternating Movements (RAM) Thumb to Fingers Hands on Lap6/26/2011 77 Maria Carmela L. Domocmat, RN, MSN
  78. 78. 6/26/2011 78 Maria Carmela L. Domocmat, RN, MSN
  79. 79. Rapid Alternating Movements (RAM) normal finding: • elderly – may be difficult – bcoz decreased reaction time and flexibility abnormal finding: • inability to perform – cerebellar dse, upper motor neuron weakness, extrapyramidal dse • dysdiadochokinesia -6/26/2011 79 Maria Carmela L. Domocmat, RN, MSN
  80. 80. Dysdiadochokinesia impairment of the ability to make movements exhibiting a rapid change of motion that is caused by cerebellar dysfunction6/26/2011 80 Maria Carmela L. Domocmat, RN, MSN
  81. 81. SENSORY SYSTEM6/26/2011 81 Maria Carmela L. Domocmat, RN, MSN
  82. 82. Light Touch, Pain, and Temperature Sensations Vibratory sensations Proprioception (sensitivity to position) Tactile discrimination (fine touch)6/26/2011 82 Maria Carmela L. Domocmat, RN, MSN
  83. 83. Light Touch, Pain, and Temperature Sensations scatter stimuli – distal and proximal parts of all extremities and trunk to cover most of dermatomes6/26/2011 83 Maria Carmela L. Domocmat, RN, MSN
  84. 84. Dermatomes6/26/2011 84 Maria Carmela L. Domocmat, RN, MSN
  85. 85. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 85
  86. 86. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 86
  87. 87. o abnormal finding anesthesia – absence of touch sensation hypesthesia – decreased sensitivity to touch hyperesthesia –increased sensitivity to touch analgesia – absence of pain sensation hypalgesia – decreased sensitivity to pain hyperalgesia – increased sensitivity to pain6/26/2011 87 Maria Carmela L. Domocmat, RN, MSN
  88. 88. • Vibratory sensations o tuning fork – bony surface fingers or big toe o usually decreased by 706/26/2011 88 Maria Carmela L. Domocmat, RN, MSN
  89. 89. • Proprioception (sensitivity to position) o Note: if position sense is intact distally, then it is intact proximally o normal finding some – sense position of great toe may be reduced o abnormal finding inability to identify directions – posterior column dse, peripheral neuropathy (e.g., diabetes, chronic alcohol abuse)6/26/2011 89 Maria Carmela L. Domocmat, RN, MSN
  90. 90. Tactile discrimination (fine touch) Tests for lesions of the sensory cortex Stereognosis Point Locations Graphestesia Two-Point Discrimination Extinction6/26/2011 90 Maria Carmela L. Domocmat, RN, MSN
  91. 91. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 91
  92. 92. http://cloud.med.nyu.edu/modules/pub/neurosurgery/sensory.html6/26/2011 Maria Carmela L. Domocmat, RN, MSN 92
  93. 93. REFLEXES6/26/2011 93 Maria Carmela L. Domocmat, RN, MSN
  94. 94. Deep tendon reflexes o biceps o brachioradialis o triceps o patellar6/26/2011 94 Maria Carmela L. Domocmat, RN, MSN
  95. 95. Biceps reflex elicited by placing your thumb on the biceps tendon and striking your thumb with the reflex hammer and observing the arm movement. Repeat and compare with the other arm.6/26/2011 95 Maria Carmela L. Domocmat, RN, MSN
  96. 96. Briceps reflex6/26/2011 96 Maria Carmela L. Domocmat, RN, MSN
  97. 97. Brachioradialis reflex striking the brachioradialis tendon directly with the hammer when the patients arm is resting. Strike the tendon roughly 3 inches above the wrist. Note the reflex supination. Repeat and compare to the other arm. The biceps and brachioradialis reflexes are mediated by the C5 and C6 nerve roots.6/26/2011 97 Maria Carmela L. Domocmat, RN, MSN
  98. 98. Brachioradialis reflex http://img.medscape.com/fullsize/migrated/408/540/mos5854.01.fig6.jpg6/26/2011 98 Maria Carmela L. Domocmat, RN, MSN
  99. 99. Triceps reflex strike the triceps tendon directly with the hammer while holding the patients arm with your other hand. Repeat and compare to the other arm .The triceps reflex is mediated by the C6 and C7 nerve roots, predominantly by C7.6/26/2011 99 Maria Carmela L. Domocmat, RN, MSN
  100. 100. Triceps reflex6/26/2011 100 Maria Carmela L. Domocmat, RN, MSN
  101. 101. Patellar reflex With the lower leg hanging freely off the edge of the bench, the knee jerk is tested by striking the quadriceps tendon directly with the reflex hammer. Repeat and compare to the other leg.The knee jerk reflex is mediated by the L3 and L4 nerve roots, mainly L4. Insult to the cerebellum may lead to pendular reflexes. Pendular reflexes are not brisk but involve less damping of the limb movement than is usually observed when a deep tendon reflex is elicited. Patients with cerebellar injury may have a knee jerk that swings forwards and backwards several times. A normal or brisk knee jerk would have little more than one swing forward and one back. Pendular reflexes are best observed when the patients lower legs are allowed to hang and swing freelly off the end of an examining table.6/26/2011 101 Maria Carmela L. Domocmat, RN, MSN
  102. 102. Patellar reflex http://cloud.med.nyu.edu/modules/pub/neurosurgery/reflexes.html http://www.brown.edu/Courses/Bio_160/Projects2000/Polio/Reflexcopy.jpg6/26/2011 Maria Carmela L. Domocmat, RN, MSN 102
  103. 103. Ankle reflex elicited by holding the relaxed foot with one hand and striking the Achilles tendon with the hammer and noting plantar flexion. Compare to the other foot.The ankle jerk reflex is mediated by the S1 nerve root.6/26/2011 103 Maria Carmela L. Domocmat, RN, MSN
  104. 104. Plantar or Achilles http://www.beltina.org/pics/achilles_tendon.jpg6/26/2011 104 Maria Carmela L. Domocmat, RN, MSN
  105. 105. Rate the reflex with the following scale: 5+ Sustained clonus 4+ Very brisk, hyperreflexive, with clonus 3+ Brisker or more reflexive than normally. 2+ Normal 1+ Low normal, diminished 0.5+ A reflex that is only elicited with reinforcement 06/26/2011 No response 105 Maria Carmela L. Domocmat, RN, MSN
  106. 106. http://www.wrongdiagnosis.com/bookimages/8/2546.png6/26/2011 106 Maria Carmela L. Domocmat, RN, MSN
  107. 107. deep tendon reflexes are graded as follows: 0 = no response; always abnormal 1+ = a slight but definitely present response; may or may not be normal 2+ = a brisk response; normal 3+ = a very brisk response; may or may not be normal 4+ = a tap elicits a repeating reflex (clonus); always abnormal6/26/2011 107 Maria Carmela L. Domocmat, RN, MSN
  108. 108. Superficial reflexeso Plantar reflexo Abdominal reflexo Cremasteric reflex6/26/2011 108 Maria Carmela L. Domocmat, RN, MSN
  109. 109. Plantar reflexThe plantar reflex (Babinski) is tested by coarselyrunning a key or the end of the reflex hammer upthe lateral aspect of the foot from heel to big toe.Normal finding : toe flexion.Abnormal finding: (+) Babinskis sign - toes extend and separate indicative of an upper motor neuron lesion affecting the lower extremity in question.6/26/2011 109 Maria Carmela L. Domocmat, RN, MSN
  110. 110. Plantar reflex6/26/2011 110 Maria Carmela L. Domocmat, RN, MSN
  111. 111. Abdominal reflex6/26/2011 111 Maria Carmela L. Domocmat, RN, MSN
  112. 112. Abdominal reflex6/26/2011 112 Maria Carmela L. Domocmat, RN, MSN
  113. 113. Cremasteric reflex6/26/2011 113 Maria Carmela L. Domocmat, RN, MSN
  114. 114. Cremasteric reflex6/26/2011 114 Maria Carmela L. Domocmat, RN, MSN
  115. 115. Other tests
  116. 116. Hoffman response elicited by holding the patients middle finger between the examiners thumb and index finger. Ask the patient to relax their fingers completely. Once the patient is relaxed, using your thumbnail press down on the patients fingernail and move downward until your nail "clicks" over the end of the patients nail. Repeat this maneuver multiple times on both hands. Normal finding: nothing occurs. Abnormal finding: (+) Hoffmans response - other fingers flex transiently after the "click". indicative of an upper motor neuron lesion affecting the upper extremity in question.6/26/2011 116 Maria Carmela L. Domocmat, RN, MSN
  117. 117. Hoffman response6/26/2011 117 Maria Carmela L. Domocmat, RN, MSN
  118. 118. Hoffmanns sign, which is elicited by flicking the distal phalanx of the long finger. A negative response, as shown here, is no motion of the thumb. A positive response is flexion of the thumb at the interphalangeal joint. 6/26/2011 118 Maria Carmelahttp://img.medscape.com/fullsize/migrated/408/540/mos5854.01.fig6.jpg L. Domocmat, RN, MSN
  119. 119. Test of Clonus Test clonus if any of the reflexes appeared hyperactive. Hold the relaxed lower leg in your hand, and sharply dorsiflex the foot and hold it dorsiflexed. Feel for oscillations between flexion and extension of the foot indicating clonus. Normally nothing is felt.6/26/2011 119 Maria Carmela L. Domocmat, RN, MSN
  120. 120. Tonus video6/26/2011 120 Maria Carmela L. Domocmat, RN, MSN
  121. 121. 6/26/2011 121 Maria Carmela L. Domocmat, RN, MSN

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