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Neurologic Examination for PC II.pptx

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The Nervous System
Dr Tsion D.
ANATOMY AND PHYSIOLOGY
• The central nervous system
– Brain
– Spinal cord
• The peripheral nervous system
– Cranial nerves (12 pairs)
– Peripheral nerves (motor and sensory fibers)
• Reflexes
• Motor and sensory pathways
Neurologic Examination for PC II.pptx
Neurologic Examination for PC II.pptx
Neurologic Examination for PC II.pptx
Neurologic Examination for PC II.pptx

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Neurologic Examination for PC II.pptx

  • 2. ANATOMY AND PHYSIOLOGY • The central nervous system – Brain – Spinal cord • The peripheral nervous system – Cranial nerves (12 pairs) – Peripheral nerves (motor and sensory fibers) • Reflexes • Motor and sensory pathways
  • 7. History • Taking the patient's history is traditionally the first step in virtually every clinical encounter. • A thorough neurologic history allows the clinician to define the patient's problem. • Solid knowledge of the basic principles of the various disease processes is essential for obtaining a good history. • As Goethe stated, "The eyes see what the mind knows."
  • 8. • Personal profile (Age, sex, address,occupation, socio-economic status). • Symptom onset (acute, sub-acute, chronic, insidious) • Duration of symptoms • Course of the condition (static, progressive, or exacerbating and remitting) • Associated symptoms such as seizures, headache, nausea, vomiting, and pain
  • 9. • Pain should be further defined in terms of the following: – Location (Ask the patient to point with one finger, if possible.) – Radiation (Pay attention to any dermatomal relationship.) – Quality (stabbing, stinging, lightninglike, pounding, etc) – Severity or quantity (Estimate functional limitation.) – Precipitating factors (stress, periods, allergens, sleep deprivation, etc) – Relieving factors (sleep, stress management, etc) – Diurnal or seasonal variation
  • 10. • Important miscellaneous factors of the history include the following: – Results of previous attempts to diagnose the condition – Any previous therapeutic intervention and the response to those treatments  A complete history often defines the clinical problem and allows the examiner to proceed with a complete but focused neurologic examination.
  • 12. Neurological examination • The neurologic examination is challenging and complex. • Neurologic examination is performed to localize a lesion in the central nervous system (CNS) or peripheral nervous system (PNS). • "History tells you what it is, and the examination tells you where it is." • The history and examination allow the neurologist to arrive at the etiology and pathology of the condition, which are essential for treatment planning.
  • 13. Tools • Reflex hammer • Penlight • Tongue blade • Safety pin • Cotton swab • A Snellen Eye Chart or pocket vision card • 128 and 512 ( or 1024) HZ tuning forks • Dermatome chart
  • 14. Neurological examination o – Mental status o – Cranial nerves o – Motor o – Reflexes o – Coordination and gait o – Sensory o – Special techniques
  • 15. • Elements of the mental status examination(MOST MENTAL STATUS) o level of consciousness o orientation o speech and language o memory o fund of information o insight and judgment o abstract thought, and calculations
  • 16. Level of consciousness • The state of awareness of the self and the environment. • Awake and alert • Lethargic - Speak to the patient in a loud voice – drowsy but open their eyes and look at you, respond to questions, and then fall asleep. • Obtunded - Shake the patient gently – open their eyes and look at you, but respond slowly and are somewhat confused. • Stupor- Apply a painful stimulus – The pt arouses from sleep only after painful stimuli. • Comatose - Apply repeated painful stimuli – A comatose patient remains unarousable with eyes closed.
  • 17. ORIENTATION • Awareness of personal identity, place ,and time. • Requires both memory and attention • Time (e.g., the time of day, day of the week, month, season, date and year, duration of hospitalization) • Place (e.g., the patient’s residence, the names of the hospital, city, and state) • Person (e.g., the patient’s own name, and the names of relatives and professional personnel)
  • 18. LANGUAGE • Assessed by observing the content of the patient's verbal and written output, response to spoken commands, and ability to read. – Fluency – Naming – Repetition – Reading – Writing – Comprehension Aphasia(LAGUAGE DIFFICULTY) vs. dysarthria(SPPECH DIFFICULTY )
  • 19. MEMORY • Should be analyzed according to three main time scales: • 1) Immediate memory :- assessed by saying a list of three items and having the patient repeat the list immediately. • 2) Short-term memory :- tested by asking the patient to recall the same three items 5 and 15 min later. • 3) Long-term memory :- evaluated by determining how well the patient is able to provide a coherent chronologic history of his or her illness or personal events.
  • 21. The Cranial Nerves • I Smell • II Visual acuity, visual fields, and ocular fundi • II, III Pupillary reactions • III, IV, VI Extraocular movements • V Corneal reflexes, facial sensation, and jaw movements • VII Facial movements • VIII Hearing
  • 22. • Cranial Nerve I—Olfactory ( usually omitted) – Use familiar and nonirritating odors e.g. coffee, lemon, soap etc... – 1st check the patency of each nostrils – With eyes closed check one nostril at a time – Odor perception, identification • Cranial Nerve II—Optic – visual acuity – visual fields ( by confrontation) – Funduscopic examination
  • 23. Visual Acuity • To test the acuity of central vision use a Snellen eye chart. • Position the patient 6meter(20 feet) from the chart. • Patients who use glasses other than for reading should put them on. • Visual acuity is expressed as two numbers (e.g., 6 /12): – The first indicates the distance of the patient from chart, and – The second, the distance at which a normal eye
  • 24. Visual Fields • Screening. • Usually sufficient to examine the visual fields of both eyes simultaneously. • Screening starts in the temporal fields because most defects involve these areas. • Face the patient at a distance of approximately 0.6–1.0 m (2–3 ft) and place your hands at the periphery of your visual
  • 26. • Further Testing • If you find a defect, try to establish its boundaries. • Test one eye at a time.
  • 27. • CN II & III—Optic and Oculomotor – Inspect the size & shape of the pupils, and compare one side with the other. – Test the pupillary reactions to light • The direct reaction (pupillary constriction in the same eye) • The consensual reaction (pupillary constriction in the opposite eye) – Always darken the room and use a bright light before deciding that a light reaction is absent. – Examine the near response (accommodation)
  • 28. CN III, IV, & VI - Oculomotor, Trochlear& Abducens • Observe for Ptosis (PROLASE OF AN ORGAN) • Test Extraocular Movements – Stand or sit 3 to 6 feet in front of the patient. – Ask the patient to follow your finger with their eyes without moving their head. – Check gaze in the six cardinal directions using a cross or "H" pattern. – Pause during upward and lateral gaze to check for nystagmus. – Check convergence by moving your finger toward the bridge of the patient's nose
  • 29. The six cardinal directions
  • 30. Cranial Nerve V—Trigeminal • Motor – the temporal and masseter muscles in turn , ask the patient to clench his or her teeth. – Note the strength of muscle contraction. • Sensory. – Pain sensation. – temperature sensation – light touch • The corneal reflex
  • 32. Cranial Nerve VII—Facial • Inspect the face, both at rest and during conversation with the patient. • Note any asymmetry and observe abnormal movements. • Ask the patient to: o 1. Raise both eyebrows. o 2. Frown o 3. Close both eyes tightly so that you cannot open them.
  • 33. Supranuclear facial palsy (obove primary motor neuron or UMI)
  • 36. CN VIII • Assess hearing. • If hearing loss is present => try to distinguish between conductive and sensorineural hearing loss. • Using a tuning fork, preferably of 512 Hz or possibly 1024 Hz. • 1) Rinne test – compare air and bone conduction • 2) Weber test
  • 37. Rinne test • In conductive hearing loss, sound is heard through bone as long as or longer than it is through air (BC = AC or BC > AC). • In sensorineural hearing loss, sound is heard longer through air (AC > BC).
  • 38. Test for lateralization (Weber test) • In unilateral conductive hearing loss, sound is heard in (lateralized to) the impaired ear. • In unilateral sensorineural hearing loss, sound is heard in the good ear.
  • 39. CN IX and X — Glossopharyngeal & Vagus • Listen to the patient's voice, is it hoarse or nasal? • Ask Patient to Swallow • Ask Patient to Say "Ah" – Watch the movements of the soft palate and the pharynx. • Test Gag Reflex (Unconscious/Uncooperative Patient) – Stimulate the back of the throat on each side. – It is normal to gag after each stimulus.
  • 40. Cranial Nerve XI—Spinal Accessory • From behind, look for atrophy or assymetry of the trapezius muscles. • Ask patient to shrug shoulders against resistance. • Ask patient to turn their head against resistance. Watch and palpate the sternomastoid muscle on the opposite side.
  • 41. Cranial Nerve XII—Hypoglossal • Listen to the articulation of the patient’s words. • Observe the tongue as it lies in the mouth. • Look for any atrophy or fasciculations • Ask patient to: – Protrude tongue – Move tongue from side to side
  • 43. The Motor system • Observation • Body position • Involuntary Movements - tremors, tics, or fasciculations • Muscle Symmetry – Left to Right – Proximal vs. Distal • Muscle Bulk – Pay particular attention to the hands, shoulders, and thighs.
  • 44. • Muscle Tone • Ask the patient to relax. • Flex and extend the patient's fingers, wrist, and elbow. • Flex and extend patient's ankle and knee. • There is normally a small, continuous resistance to passive movement. • Observe for decreased (flaccid) or increased (rigid/spastic) tone. • Muscle Strength
  • 46. • Test the following: – Flexion at the elbow (C5, C6, biceps) – Extension at the elbow (C6, C7, C8, triceps) – Extension at the wrist (C6, C7, C8, radial nerve) – Squeeze two of your fingers as hard as possible (test hand grip)... ( C7, C8, T1) – Finger abduction (C8, T1, ulnar nerve) – Oppostion of the thumb (C8, T1, median nerve) – Flexion at the hip (L2, L3, L4, iliopsoas)
  • 47. – Adduction at the hips (L2, L3, L4, adductors) – Abduction at the hips (L4, L5, S1, gluteus medius and minimus) – Extension at the hips (S1, gluteus maximus) – Extension at the knee (L2, L3, L4, quadriceps) – Flexion at the knee (L4, L5, S1, S2, hamstrings) – Dorsiflexion at the ankle (L4, L5) – Plantar flexion (S1)
  • 48. Coordination • Coordination of muscle mov’t requires that four areas of the NS function in an integrated way: – The motor system, for muscle strength – The cerebellar system, for rhythmic movement and steady posture – The vestibular system, for balance and for coordinating eye, head, and body movements – The sensory system, for position sense
  • 49. • To assess coordination, observe the pt’s performance in: o Rapid alternating movements o Point-to-point movements o Gait and other related body movements o Standing in specified ways.
  • 50. Rapid Alternating Movements – Ask the patient to strike one hand on the thigh, raise the hand, turn it over, and then strike it back down as fast as possible. – Ask the patient to tap the distal thumb with the tip of the index finger as fast as possible. – Ask the patient to tap your hand with the ball of each foot as fast as possible.
  • 51. Point-to-Point Movements – Ask the patient to touch your index finger and their nose alternately several times. Move your finger about as the patient performs this task. – Hold your finger still so that the patient can touch it with one arm and finger outstretched. Ask the patient to move their arm and return to your finger with their eyes closed. – Ask the patient to place one heel on the opposite knee and run it down the shin to the big toe. Repeat with the patient's eyes closed.
  • 52. Gait • Walk across the room, then turn, and come back. • Walk heel-to-toe in a straight line (tandem walking). • Walk on the toes, then on the heels— sensitive tests respectively for plantar flexion and dorsiflexion of the ankles, as well as for balance. • Hop in place on each foot in turn. • Do a shallow knee bend, first on one leg, then on the other.
  • 53. Stance • THE ROMBERG TEST – This is mainly a test of position sense. – The patient should first stand with feet together and eyes open. – Then close both eyes for 20 to 30 seconds without support. – Note the patient’s ability to maintain an upright posture. • TEST FOR PRONATOR DRIFT – The patient should stand for 20 to 30 seconds with both arms straight forward, palms up, and with eyes closed. – A person who cannot stand may be tested for a pronator drift in the sitting position.
  • 55. Deep Tendon Reflexes • The patient must be relaxed and positioned properly before starting. • Reflex response depends on the force of your stimulus. Use no more force than you need to provoke a definite response. • Reflexes can be reinforced by having the patient perform isometric contraction of other muscles (clenched teeth).
  • 57. • Biceps (C5, C6) • Triceps (C6, C7) • Brachioradialis (C5, C6) • Knee (L2, L3, L4) • Ankle (S1, S2) • Abdominal Reflex – lightly but briskly stroking each side of the abdomen, above (T8, T9, T10) and below (T10, T11, T12) the umbilicus. – Note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus.
  • 58. • The Plantar Response (L5, S1) – Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key. – Note movement of the toes, normally flexion (withdrawal). – Extension of the big toe with fanning of the other toes is abnormal. This is referred to as a positive Babinski. • Clonus • If the reflexes seem hyperactive, test for ankle clonus: – Support the knee in a partly flexed position. – With the patient relaxed, quickly dorsiflex the foot.
  • 60. • To evaluate the sensory system, you will test several kinds of sensation: – Pain and temperature (spinothalamic tracts) – Position and vibration (posterior columns) – Light touch (both of these pathways) – Discriminative sensations, which depend on some of the above sensations but also involve the cortex
  • 61. • General – Explain each test before you do it. – Unless otherwise specified, the patient's eyes should be closed during the actual testing. – Compare symmetrical areas on the two sides of the body. – Also compare distal and proximal areas of the extremities. – When you detect an area of sensory loss map out its boundaries in detail.
  • 62. • Vibration • Use a low pitched tuning fork (128Hz). – Test with a non-vibrating tuning fork first to ensure that the patient is responding to the correct stimulus. – Place the stem of the fork over the distal interphalangeal joint of the patient's index fingers and big toes. – Ask the patient to tell you if they feel the vibration. • If vibration sense is impaired proceed proximally: – Wrists – Elbows
  • 63. • Subjective Light Touch • Use your fingers to touch the skin lightly on both sides simultaneously. • Test several areas on both the upper and lower extremities. • Ask the patient to tell you if there is difference from side to side or other "strange" sensations.
  • 64. Position Sense • Grasp the patient's big toe and hold it away from the other toes to avoid friction. • Show the patient "up" and "down." • With the patient's eyes closed ask the patient to identify the direction you move the toe. • If position sense is impaired move proximally to test the ankle joint. • Test the fingers in a similar fashion. • If indicated move proximally to the metacarpophalangeal joints, wrists, and
  • 65. • Dermatomal Testing • If vibration, position sense, and subjective light touch are normal in the fingers and toes you may assume the rest of this exam will be normal. • Pain • Use a suitable sharp object to test "sharp" or "dull" sensation. • Test the following areas: – Shoulders (C4) – Inner and outer aspects of the forearms (C6 and T1)
  • 66. • Temperature • Often omitted if pain sensation is normal. • Use a tuning fork heated or cooled by water and ask the patient to identify "hot" or "cold." • Light Touch • Use a fine whisp of cotton or your fingers to touch the skin lightly. • Ask the patient to respond whenever a touch is felt.
  • 67. Discrimination • Since these tests are dependent on touch and position sense, they cannot be performed when the tests above are clearly abnormal. • Graphesthesia – With the blunt end of a pen or pencil, draw a large number in the patient's palm. – Ask the patient to identify the number. • Stereognosis – Use as an alternative to graphesthesia. – Place a familiar object in the patient's hand (coin, paper clip, pencil, etc.). – Ask the patient to tell you what it is.
  • 68. Two Point Discrimination – Use in situations where more quantitative data are needed, such as following the progression of a cortical lesion. – Use an opened paper clip to touch the patient's finger pads in two places simultaneously. – Alternate irregularly with one point touch. – Ask the patient to identify "one" or "two." – Find the minimal distance at which the patient can discriminate.
  • 69. Special Techniques • Asterixis • Meningeal signs – Nuchal rigidity or neck stiffness – Brudzinski sign(in meningitis, involuntary flexion of the knees and hips following flexion of the neck while supine) – Kernig sign
  • 70. Approach to Unconscious Patient • Consciousness:Is a state of awareness of internal and external stimuli coupled with the ability to react to these stimuli either by thought or by direct physical movement. • It is dependent upon the integrity and interaction between the cerebral cortices and arousal system (ARAS)
  • 71. • Four questions demand immediate answer? 1. Are the vital functions intact or compromised? 2. How deep is the coma? 2. Is there raised intracranial pressure with actual or impending tentorial herniation? 4. What is the cause of coma and is the cause remediable?
  • 72. • Take a history from relatives or friends •Was there any preceding illness? • Fever and headaches before coma would suggest malaria or meningitis •Was the onset of coma sudden or gradual?
  • 73. Neurologic examination of comatos patient • The state of responsiveness • Brain stem reflex • Motor examination
  • 74. Assessing the state of responsiveness THE GCS (glasgow coma scale) This is a score that describes the depth of coma It should be carried out on every comatose patient It allows effective communication with
  • 76. Investigations • CBC • Blood film • Glucose measurements • Arterial blood gas analysis • Electrolytes • BUN & creatinine • Toxicologic analysis of blood & urine • Blood and urine cultures • CSF examination
  • 77. MANAGMENT • Important principles are – Look after the Airway Breathing and Circulation first – stabilize the patient with cervical spine injuries – Draw blood for lab studies – Rapidly diagnose and treat the treatable causes, like malaria, meningitis, hypoglycaemia and hypertension – Monitor the patient closely for any deterioration in their GCS, or change in
  • 78. • The main objective of therapy is to find the cause and remove. • Others supportive management like 1. Maintain clear air way 2. Give O2 3. Keep patient in semi-prone position 4. Suspect hypoglycemia in every case and give 1-2 ml of 25% dextrose water
  • 79. 5. If the patient is in shock, start rapid infusion of( blood plasma or normal saline) 6.Control of temperature hypo or hyper tremie 7.Cerebral edema should be corrected giving IV mannitol & dexamethasone 8. Give adequate nutrition via NG tube when the patient is stable
  • 80. 9. Prevent bedsores 10.Care for oral hygiene 11.Catheterize the bladder 12.Care of bowel
  • 81. Prognosis of coma • Depends on the cause of the coma. • Metabolic comas have a far better prognosis than traumatic ones. • factors such as age, underlying systemic disease, and general medical condition
  • 82. • GCS-. Patients scoring 3 or 4 have an 85% chance of dying or remaining vegetative, while scores >11 indicate only a 5–10% likelihood of death or vegetative state and 85% chance of moderate disability or good recovery • For anoxic and metabolic coma, clinical signs such as the pupillary and motor responses after 1 day, 3 days, and 1 week have been shown to have