NEUROLOGICAL EXAMINATION KABILAN.A… (MSC.,(N),PGDHM,PGDPH) LECTURER., MANIPAL COLLEGE OF MEDICAL SCIENCES
INTRODUCTION: A neurological examination is theassessment of sensory neuron and motorresponses, especially reflexes, to determinewhether the nervous system is impaired. Thistypically includes a physical examination and areview of the patients medical history but notdeeper investigation such as neuroimaging. Itcan be used both as a screening tool and as aninvestigative tool.
Examples of Definitions• Alert:o awake, looks abouto responds in a meaningful manner to verbal instructions orgestures• Drowsy:o oriented when awake but if left alone will sleep• Confused:o disoriented to time, place, or persono memory difficulty is commono has difficulty with commandso exhibits alteration in perception of stimuli, may be agitated
• Stuporous:o generally unresponsive except to vigorous stimulationo may make attempt at verbalization to vigorous/repeatedstimulio Opens eyes to deep pain• Comatose:o unarousable and unresponsiveo some localization or movement may be acceptable withinthe comatose categorydepending on the coma definitions e.g. light coma to deepcomao Does not open eyes to deep pain
The difference between Coma and Sleep:• sleeping persons respond to unaccustomed stimuli• sleeping persons are capable of mental activity (dreams)• sleeping persons can be roused to normal consciousness• cerebral oxygen uptake does not decrease during sleep as it often does in coma
Special States of Altered Levels of Consciousness• Brain Death: An irreversible loss of cortical and brain stem activity.• Persistent Vegetative State: A condition that follows severe cerebral injury inwhich the altered state becomeschronic or persistent.• Locked-in Syndrome: A state of muscle paralysis, involving voluntarymuscles, while there is preservation of fullconsciousness and cognition.
Indications:A neurological examination is indicated whenever aphysician suspects that a patient may have a neurologicaldisorder. Any new symptom of any neurological order maybe an indication for performing a neurological examination.
Organic Disease ? Signs &/or symptoms that cannot be faked must be examined closely. Examples include, asymmetry in pupils, abnormal retinal exams, nystagmus, muscle atrophy, and muscle fasciculation.
Where are the Connections Upper Motor Neurons (UMN) are defined as the connections of motor nerves before they leave the spinal cord Lower Motor Neurons (LMN) are defined as after the synapse (connection) into the peripheral nerve cell bodies.
Objectives Organize Exam into the 6 Subsets of Function Concept of Screening Examination Understand Afferent and Efferent Pathways for Brainstem Reflexes Differentiate Between Upper and Lower Motor Neuron Findings
Six Subsets of the Neuro Exam Here’s what you need to examine. Mental Status Cranial Nerves Motor Sensory Coordination Reflexes
Concept of a Screening Exam Screening each of the subsets allows one to check on the entire neuroaxis (Cortex, Subcortical White Matter, Basal Ganglia/Thalamus, Brainstem, Cerebellum, Spinal Cord, Peripheral Nerves, NMJ, and Muscles) Expand evaluation of a given subset to either • Answer questions generated from the History • Confirm or refute expected or unexpected findings on Exam
Neurological Examination Mental Status Exam “FOGS” Family story of memory loss Orientation General Information Spelling &/or numbers Recognition of objects
1. INTERVIEW The patient/family interview will allow the nurse to:• ƒgather data: both subjective and objective about the patients previous/present health state• ƒprovide information to patient/family• ƒclarify information• ƒmake appropriate referrals• ƒdevelop a good working relationship with both the patient and the family• ƒinitiate the development of a written plan of care which is patient specific
Interview to identify presence of:• headache• difficulty with speech• inability to read or write• alteration in memory• altered consciousness• confusion or change in thinking• disorientation• decrease in sensation, tingling or pain• motor weakness or decreased strength• decreased sense of smell or taste• change in vision or diplopia• difficulty with swallowing• decreased hearing• altered gait or balance• dizziness• tremors, twitches or increased tone
Physical Examination Considerations• Level of Consciousness – Most important aspect of neurologic examination – Level of consciousness first to deteriorate; changes often subtle, therefore requiring careful monitoring.• Consciousness: – Composed of Two Components: • Arousal (Alertness) • Awareness (Content) – Assessment: Orientation vs. Disorientation » Person, Place & Time » Varying sequence of questions is important !!
Assessing LOC• Glasgow Coma Scale (GCS) – Three Categories: • Eye opening • Best motor response • Best verbal response – Scoring • Highest or best possible score 15 • A score of < 8 indicates coma • Lowest or worst possible score 3
Pupillary Examination• The pupillary examination can be quickly and easily performed in the unconscious or minimally responsive patient when a TBI is suspected, and can provide valuable information about the degree of initial or progressing brain injury. Several types of TBI’s may cause pupillary changes, which indicate the need for rapid interventions to decrease ICP caused by cerebral bleeding and/or edema. Nurses are in a key position to detect early changes in a patients condition and administer or advocate for immediate interventions.
Check pupil size in lighted room, andreactivity to light in a darkened room.
Unequalpupil sizecan be a signof a seriousbrain injury.
Brain Injury with bleeding or swellingRapid interventionsare needed to preventdeath or permanentbrain damage – TBI’scan progress rapidly!
Mental StatusLevel of Alertness • Subjective view of Examiner • Definition of Consciousness • Terminology for Depressed Level of Consciousness • Concept of Coma • DeleriumDegree of Orientation • To what?
Mental StatusConcentration • Serial 7’s or 3’s • “WORLD” backwards • Months of the Year Backwards • Try to quantify degree of impairment * A and O and Concentration need to be intact for other aspects of the Mental Status Exam to have localizing value!
Mental Status MemoryImmediate Recall • A task of concentrationShort-Term Memory • “3/3 objects after 5 minutes”Long-Term Memory • Last thing to go
Mental Status LanguageAphasia vs DysarthriaReceptive Language • Command FollowingExpressive Language • Fluency • Word FindingRepetition • Screens for Receptive, Expressive, and Conductive Aphasias
Mental Status Calculations, R-L confusion, finger agnosia, agraphia • Gerstmann’s Syndrome (Dominant Parietal Lobe) Hemineglect • Non-Dominant Parietal Lobe Delusional Thinking, Abstract Reasoning, Mood, Judgement, Fund of Knowledge, etc • Important for Psychiatry • Does not localize well to one region of the cortex • Neurocognitive Testing required to get at more specific deficits
Strength Medical Research Council Scale 5/5 = Full Strength 4/5 = Weakness with Resistance 3/5 = Can Overcome Gravity Only 2/5 = Can Move Limb without Gravity 1/5 = Can Activate Muscle without Moving Limb 0/5 = Cannot Activate Muscle
WeaknessDescribe the Distribution of Weakness • Upper Motor Neuron Pattern • Peripheral neuropathy Pattern • Myopathic Pattern
Tone Tone is the resistance appreciated when moving a limb passively “Normal Tone” Hypotonia • “Central Hypotonia” • “Peripheral Hypotonia” Increased Tone • Spasticity (Corticospinal Tract) • Rigidity (Basal Ganglia, Parkinson’s Disease) • Dystonia (Basal Ganglia)
Drift AssessmentDrift Assessment: test for motor weaknessArm: hold arms out with palms up; eyes closed• Pronator drift: hands pronate (roll over);• Motor drift: arm “drifts” downward• Cerebellar drift: arm “drifts” back toward head or out to sideLeg: no need to close eyesmotor: leg “drifts”toward bed
Movement AssessmentMovements are purposeful or non-purposeful purposeful: picking at tubings or bed linens, scratching nose localizing: moving toward or removing a painful stimulus; must cross the midline; occurs in the cortex withdrawal: pulling away from pain; occurs in the hypothalamusnon-purposeful: do not cross the midline abnormal flexion: (decorticate) rigidly flexed arms and wrists; fisted hands; occurs in upper brainstem abnormal extension: (decerebrate) Decorticate rigidly, rotated inward extended arms with flexed wrists and fisted hands; occurs in midbrain or pons. Decerebrate
Pain and Temperature • Pinprick (One pin per patient!) • Sensation of Cold • Look for Sensory Nerve or Dermatomal Distribution Vibration Sensation • C-128 Hz Tuning Fork (check great toe) Joint Position Sensation • Check great toe • Romberg Sign
Higher Cortical Sensory Function Graphesthesia Stereognosis Two-Point Discrimination Double Simultaneous Extinction Gerstmann’s Syndrome (acalculia, right-left confusion, finger agnosia, agraphia) • Usually seen in Dominant Parietal Lobe lesions
Hemisphere Dysfunction Dysmetria on Finger-Nose-Finger Testing* Irregularly-Irregular Tapping Rhythm* Dysdiadochokinesis* Impaired Check* Hypotonia* Impaired Heel-Knee-Shin* Falls to Side of Lesion* Nystagmus (Variable Directions) * All Deficits are Ipsilateral to the side of the lesion
Abmornal ReflexesAbnormal Reflexes: Babinski: initial inflection of great toe in response stroking of sole; upgoing toe is abnormal Grasp: involuntary grasp in response to stimulation of palm; abnormal in an adult Doll’s eyes: impairment of eye movement to opposite side when head is turned = damage to brainstem; no movement = loss of brainstem
Neuro Aessessment Quiz• 1. Peripheral Nervous System (PNS) • .4. A Coup Contracoup injury is defined as: When the head strikes a fixed object, is made up of the following except:: the coup injury occurs at the site of impacta) Cranial nerves (12) and the contrecoup injury occurs at theb) Ventricles opposite side. True or False____________________c) Axons and Neurons • 5. The Facial nerve controls:d) Spinal nerves (31) a) Movement of the chin, tongue and parotide) Cerrebellar nerves glands.• 2. The Autonomic Nervous System b) Movement of the tongue, soft palete and contains both the Sympathetic eyebrows. Division of nerves and the c) Movement of the chin and cheeks Parasympathetic Division of nerves. muscles. True or False________________. d) Movement of all the facial expression• 3. Intracranial Hemorrhage can occur muscles. in the following places except: • 6. Which nerve controls movement on the neck and shoulders?a) Epidural space a) Abducensb) Subdural space b) Accousticc) Subarachnoid space c) Spinal Assesoryd) Ethmoid space d) Occulomotor
• 7. A serious injury to the cervical spine • 9. When assessing a patient with altered LOC, and spinal cord most likely will result in you feel his state of awareness/arousal is best the following condition: described as “Obtunded”, this means:a) Hemiplegia a) Very drowsy, when not stimulated, but canb) Quadraplegia follow simple commands when stimulated (i.e.c) Paraplegia shaking or shouting); verbal responses include one or two words, but will drift back to sleepd) Contralateral paralysis without stimulation.• 8. Any suspected head, neck or spine b) A state of drowsiness; client needs increased injured victim should immediately be external stimuli to be awakened but, remains given spinal immobilization precautions, easily arousable; verbal, mental & motor except: responses are slow or sluggish.a) When the victim complains of pain only c) Awakens only to vigorous and continuous upon turning his head to one side. noxious (painful) stimulation; minimalb) When the victim refuses to allow spinal spontaneous movement; motor responses to immobilization even after listening pain are appropriate but, verbal responses are carefully to multiple attempts to explain minimal and incomprehensible (i.e. moaning). the dangers and risk involved. d) Vigorous external stimulation fails to producec) When the victim is intoxicated on alcohol any verbal response; both arousal and and cannot speak clearly. awareness are lacking; no spontaneousd) When the victim was never unconscious movements but, motor responses to noxious and denies any pain. stimuli maybe be purposeful
• 10. The Glasgow Coma scale tests for • 13. A constricted “pin point” pupil indicates: three kinds of responses, they are: (best answer)a) Eye Opening a) Brain Stem herniationb) Motor Response b) Cardiac Arrestc) Verbal Response c) Cerebral Infarction of the parietal lobed) Auditory Response d) Cerebral Infarction of the occipital lobe• 11. The best and worst possible score on e) A wide variety of conditions, some being the GCS is: extremely life threatening.a) 15 and 0 • 14. What Cranial nerve(s) controls theb) 13 and 3 movement of the eyes down and in?c) 15 and 3 a) CN VI Abducensd) 18 and 5 b) CN III Oculomotor• 12. When assessing pupillary response, c) CN IV Trochlear you are looking for the following d) CN II Optic conditions except: • 15. The Motor strength scale goes from 0/5 toa) Coordinated eye movement and bilateral 5/5, 0 being no strength at all and 5 being blinking. normal strength. A person with a motor strengthb) Reactivity to and accommodation to light. of 4/5 would be:c) Symmetry of pupils and accommodation a) overcomes gravity; offers no resistance to light. b) strong against resistanced) Abnormal pupil shape. c) weak against resistance d) no muscle movement
• 16. Match the following postures with its definition: • Answers• Decerebrate_____________ • 1 e• Decorticate______________ • 2 True • 3 da) Abnormal flexion: rigidly flexed arms and • 4 True wrists; fisted hands; occurs in upper • 5 d brainstem • 6 cb) Abnormal extension: rigidly, rotated inward, extended arms with flexed wrists • 7 b and fisted hands; occurs in midbrain or • 8 b pons. • 9 a• 17. The Babinski reflex is the initial • 10 d inflection (extension) of great toe in • 11 c response stroking of the sole of the foot, select the correct answer: • 12 aa) An upgoing great toe is abnormal. • 13 eb) An upgoing great toe is normal. • 14 cc) An upgoing great toe is abnornal in • 15 c adults. • 16 Decer = b. Decor = ad) An upgoing great toe is normal in infants. • 17 c&d