CVA cerebrovascular accidant - History taking and OSCE


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note about CVA , very intersting and very useful for student and doctors
contain proper way to compose and take very nice history and guidance to dignosis

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  • Complete weakness within 48hours
  • CVA cerebrovascular accidant - History taking and OSCE

    1. 1. بسم الله الرحمن الرحيم CVA Academic group OF internal medicine - Revision note of CVA- 2010 Dr. Mohamed Eisam Elhag Mahmoud MBBS, Alneelain University Faculty of Medicine Note: Dr. Mohammed Isam Al-Hajj does not have any financial relationships to disclose nor will he discuss any non-approved drug or device uses.
    2. 2. # Personal History: <ul><li>-name </li></ul><ul><li>-age : usually in elderlly but there is some cases in young!! </li></ul><ul><li>Q-causes of CVA in young? </li></ul><ul><li>A.V.M </li></ul><ul><li>CVS disease => embolism , A.F , post MI </li></ul><ul><li>Premature atherosclerosis </li></ul><ul><li>Arterial Disection </li></ul>
    3. 3. <ul><li>Therombophilia </li></ul><ul><li>Antiphospholipid “anticardiolipin syndrome” </li></ul><ul><li>Vasculitis , SLE </li></ul><ul><li>Bleeding disordor </li></ul><ul><li>Berry aneursm </li></ul>
    4. 4. <ul><li>-sex. – residance . –tribe . –occupation . – marital state </li></ul><ul><li>* Pt. is Rt. / or Left handed => “ dominant hemisphere” </li></ul><ul><li>- D.O.A:- pt. admitted at twinty second of / /2010. </li></ul><ul><li># C/O: Rt. Side weakness , which preceded by numbness. </li></ul>
    5. 5. #HPI:- “ pridiposing Factors must mention at first ” <ul><li>If the => pt. is known case of:- </li></ul><ul><li>1- HTN for 5 yr , recived captopril&not on regular ttt. </li></ul><ul><li>2- DM for 7 yrs ,on oral hypoglycemic agent but not on regular medication. </li></ul><ul><li>3- Mitral stenosis for 4 yrs, not recived digoxine. </li></ul>
    6. 6. <ul><li>The condition started 1 day P.T.A by weakness which is:- </li></ul><ul><li>Onset: </li></ul><ul><li>Sudden -> Embolism “with maximum intensity at the begin” </li></ul><ul><li>Rapid-> Therombosis”pt.weak up from sleep then after few hours develop weakness “ </li></ul><ul><li>Drammatic-> Haemorrhage “when pt. do his ordinary activity” </li></ul>
    7. 7. <ul><li>Gradual -> SOL “focal lesion then>>>-progress” </li></ul><ul><li>Intermittent -> multiple sclerosis “ scatterd in place ,time & disease . may in young , ex. Pt. blind >>>then monoplegia. </li></ul><ul><li>Trauma !! </li></ul>
    8. 8. <ul><li>2- The condition ass ot ass with Coma => cortical lesion </li></ul><ul><li>3- The weakness ass ot ass with sign of incrase IC P =>SOL “headach, convulsion , loss of consciousness” </li></ul><ul><li>4- The weakness ass ot ass with Fever & Convulsion => absccess & granuloma </li></ul><ul><li>5- The weakness ass ot ass with Sphintric disturbance => anterior cerebral artery. </li></ul>
    9. 9. <ul><li>6- The weakness ass ot ass with Cranial nerves disturbance “ especially 7 th => mouth devation” </li></ul><ul><li>-7 th C.N palsy + weakness at same side -> un-crossed hemiplegia “ at level of cerebral cortex” </li></ul><ul><li>- 7 th C.N palsy + weakness at opposite side=> crossed hemiplegia” at the level of Brain stem” </li></ul>
    10. 10. 7- The weakness ass ot ass with Speech disturbance => cortical lesion. <ul><li>Aphasia </li></ul><ul><li>Sensory: can talk but can not understand.=fluent=receptive, ask him to follow your command?ex. touch your right ear with left hand? </li></ul><ul><li>Motor: can understand but can not talk.= nonfluent=expressive. Ask him to till you the pen parts? ( most common “Brocas aphasia” </li></ul><ul><li>Global: sensory + motor </li></ul>
    11. 11. <ul><li>Dysphasia => cortex </li></ul><ul><li>Dysartheria => internal capsule , Brain stem , may cerebllum, basal ganglia, Tongue ex. Aphthous ulcer. ( slurred,staccato,scanning) </li></ul><ul><li>Dysphonia: volume of speech=> vocal cord:- innervation, candida,papilloma. </li></ul>
    12. 12. <ul><li>THEN , complete the CNS analysis:- </li></ul><ul><li>- SENSORY => no/ there parathesia , numbness,…. </li></ul><ul><li>- remaining of cranial nerves: </li></ul><ul><li>Normal smelling, no visual disturbance, no double vision , no affection of eyes movment, difficult in mastication,affect of face sensation, jaw hang, deviation of mouth, accumulation of food ,loss of hearing, balance disturbanc , change in voice, difficult in swalowing, no diffecult in speech, can rise his shoulder, rotate his neck. </li></ul>
    13. 13. <ul><li>Degree of disability: cant walk, walk with asscistance. </li></ul><ul><li>Cerebellar sign </li></ul>
    14. 14. # systemic review: <ul><li>CVS: valvular lesion => shooting embolus. (no chest pain , no palpatation “imp. Negative”). MI->shooting thrombus. </li></ul><ul><li>RS: TB => tubercloma act as SOL. </li></ul><ul><li>GIT: espcially Diarrhea -> dhydation->>thrombotic state. </li></ul><ul><li>Renal : polycystic kidney->ass e sacular aneyrsum->may rupture “ Haemorrage” </li></ul><ul><li>Skin: any skin rash or Bleeding=>bleeding tendancy “haeg.” </li></ul><ul><li>Gynoclogical: menarch,menopause , amount => increase bleeding tendancy. </li></ul>
    15. 15. # PMH:- <ul><li>T.I.A : transient neurological deficit”ischemic”, with complete recovery within 24h. </li></ul><ul><li>R.I.N.D : reversible ischemic neurological deficit”=>recovery from 24h---7days. </li></ul><ul><li>Simillar condition. *causes of recurrent stroke? Multiple sclerosis, CVS disease not treated well,bleeding tendancy. </li></ul><ul><li>No DM , no HTN </li></ul><ul><li>TB, syphilis => act as SOL. </li></ul><ul><li>Hospitilization & blood tranfusion-> (HIV,Toxoplasma,1ry CNS lymphoma). </li></ul>
    16. 16. <ul><li>#FH: DM, HTN, simillar condition->PKD, familial hyperlipidemia, bleeding tendancy. </li></ul><ul><li>#Drug history: </li></ul><ul><li>Not known to be sensitive to any medication known to him/her including pencillin. </li></ul><ul><li>On regular medication: oral contraceptive=> increase viscosity of blood->> thrombotic. </li></ul><ul><li>Antiplatelet ,anticoagulant,NSAID,steroid . </li></ul>
    17. 17. <ul><li># social history: housing condition , educational level,jop,health insurance, sibling =>(to know who is take care of pt.) ,bad habites->smooking,alcoholic. Classes(low/modrate/high)socioeconomic class. </li></ul>
    18. 18. <ul><li>#summery:- 68yr old male , known case of HTN for 5 yrs not on regular medication, present with Rt. Side weakness, the condition ass with aphasia & loss of consciousness. </li></ul>
    19. 19. O/E: <ul><li>General: looks ill, lay flat, average wt.& height , not tachypnic or orthopnic, has NG-tube in his Rt. Nostril, canulated in Rt. Hand </li></ul><ul><li>Vital signs: BP , PR ,RR , Temp. </li></ul>
    20. 20. Neurologically: <ul><li>Oriented in t ime, p lace & p erson </li></ul><ul><li>Memory for remote ,recent&immediate events are intact. </li></ul><ul><li>In good mood , good bhaivours & intelligent. </li></ul><ul><li>He suffer from motor aphasia </li></ul>
    21. 21. Cranial nerves examination …….. <ul><li>Motor System:- </li></ul><ul><li>Posture </li></ul><ul><li>Abnormal movment </li></ul><ul><li>Trophic change </li></ul><ul><li>Wasting </li></ul>
    22. 22. Motor examination <ul><li>Inspection </li></ul><ul><li>Tone </li></ul><ul><li>Power </li></ul><ul><li>Reflexes </li></ul><ul><li>Coordination </li></ul>
    23. 23. <ul><li>Tone: </li></ul><ul><li>Hypertonia “spastic” 1may be+clonus, if hypotonia=>spinal shock. </li></ul><ul><li>- Power : </li></ul><ul><li>determin grade of power. </li></ul><ul><li>examine each group” weakest”, </li></ul><ul><li>- Reflexes: </li></ul><ul><li>deep-> tendon. </li></ul><ul><li>Superficial-> planter reflex , abdominal reflex. </li></ul>
    24. 24. <ul><li># Sensory:- according to dermatome </li></ul><ul><li>1-Superficial: touch, pin prick </li></ul><ul><li>2- Deep : vibration, position sense. </li></ul><ul><li>3- Cortical sensation: asterogenosis , tow points discrimination , sensory intention, apraxia,graphesia. </li></ul><ul><li>if there any disturbance=> </li></ul><ul><li>Coordination </li></ul><ul><li>Gait : circumduction </li></ul><ul><li>Back examination. </li></ul>
    25. 26. <ul><li>Then Examine: </li></ul><ul><li>CVS: for irregular irregular pulse-> Atrial fibrillation </li></ul><ul><li>Pericardium ->underling valvular lesion. </li></ul><ul><li>Carotid pulse& carotid bruit. </li></ul><ul><li>Eyes: DM retinopathy, HTN retinopathy, Arcus senile. </li></ul><ul><li>Examine other systems. </li></ul>
    26. 27. Q- How to investigate this pt? <ul><li>CT-scan : immediately done to role out haemorage, but infarction will visualize up to 12 h. </li></ul><ul><li>MRI: gold stander investigation </li></ul><ul><li>Carotid Doppler: to show stenosis , if there + pt.=> for Endoarterectomy. </li></ul><ul><li>Investigation for underling causes: </li></ul><ul><li>Blood sugar, cholesterol level , Hb , </li></ul><ul><li>ECG, Echo. , </li></ul><ul><li>ANA , Anti-DNA , Anti-thrombin III , Protein C & S , Urine. </li></ul>
    27. 28. Q- what are the risk factors for stroke? <ul><li>1- Non – modifiable: </li></ul><ul><li>Age, gender “m>f “ , hereditary , previous vascular events(MI – stroke – peripheral embolism). </li></ul><ul><li>2- Modifiable: </li></ul><ul><li>HTN , cigarette smoking , DM , Hyperlipidemia , HF , AF , alcoholic , + FH , oral pill , & polycythamia. </li></ul>
    28. 29. Q- What is your dignosis? <ul><li>CVA, Rt. Side hemiplegia due to left cortical lesion which result of Embolism from cardiac source “mitral stenosis complicated by atrial fibrillation “ associated with Rt. UMN Fascial Nerve palsy “ uncrossed hemiplegia” , pt. has motor aphasia, now pt. is improved slightly . </li></ul>
    29. 30. Q- where is the site of lesion? <ul><li>A- Cortical: </li></ul><ul><li>Convulsion </li></ul><ul><li>Coma => impair consciousness </li></ul><ul><li>Un-crossed hemiplegia -> power different </li></ul><ul><li>Homenumus hemnopia </li></ul><ul><li>Aphasia => if lesion affect dominant hemisphere </li></ul><ul><li>Absence of cortical sensation. </li></ul>
    30. 31. <ul><li>B- Internal capsule: </li></ul><ul><li>Deep hemiplegia </li></ul><ul><li>Deviation of mouth “uncrossed” </li></ul><ul><li>Dysphagia -> risk aspiration pneumonia </li></ul><ul><li>UMN Fascial palsy –same side </li></ul><ul><li>No convulsion, No coma, No aphasia, No hemnumous heminopia. </li></ul>
    31. 32. <ul><li>C- Brain stem: </li></ul><ul><li>Symptoms </li></ul><ul><li>(4D)=> Dysartheria,Dysphonia, Diplopia&Dysphagia. “ipsilateral C.N dysfunction”. 3 RD C.N palsy, impair upgaze. </li></ul><ul><li>Fascial palsy usually LMN </li></ul><ul><li>C rossed : </li></ul><ul><li>Contralateral spastic hemiparesis </li></ul><ul><li>Hyperreflexia & extensor plantar response (UMN). </li></ul><ul><li>Contralateral hemisensory loss & ipsilateral incoordination. </li></ul>
    32. 33. Q- what is the nature of lesion? Haemorrage Infraction embolism thrombosis Dramatic onset Occure when pt in his/her ordinary activity Sudden onset with max. intensity at the begin Rapid onset when pt. weak up from sleep then within hours weakness at maximum onset. Also condition associated with: Vomiting Convulsion fever Usually there is clear source of embolism. Ex. . cardiac -> preceded palpitation . Fat embolism ” bone fracture” . air embolism . pulmo. Embolism -> VSD “paradoxical embolism” Source: . HF . MI
    33. 34. Q- What is the complications of stroke? <ul><li>1- Chest infection. 2-Dhydration. </li></ul><ul><li>3- hyponatremia. 4-hypoxemia. 5- seizures. </li></ul><ul><li>6- DVT & pulmonary embolism. </li></ul><ul><li>7-Frozen shoulder. 8-Bed sore. </li></ul><ul><li>9-urinary infection. 10- constipation. </li></ul><ul><li>11- psychological harmfull. </li></ul><ul><li>  </li></ul>
    34. 35. Q- How to manage such pt.? <ul><li>General : </li></ul><ul><li>Psychological support </li></ul><ul><li>Frequent change position to prevent bed sore. </li></ul><ul><li>NG- Tube </li></ul><ul><li>Urinary catheterization. </li></ul><ul><li>Physiotherapy-> to prevent wasting & contraction. </li></ul><ul><li>Specific: for underling cause </li></ul>
    35. 36. <ul><li>Q- what are the poor prognostic factors of CVA? </li></ul><ul><li>Elderly 2- co-morbid disease 3-re-infraction 4-haemorage inside infraction 5- coma 6-hypoxemia 7-hypercapnia 8-itrogenic->rapid decrease of high BP. </li></ul>
    36. 37. <ul><li>Q- mention extracranial sites of thromboembolism? </li></ul><ul><li>1-carotid &its branches 70% . 2- heart 20% (AF) 3-5%different </li></ul><ul><li>  </li></ul><ul><li>Q- mention risk factors for haemorragic stroke? </li></ul><ul><li>HTN, AVM , Bleeding disorders, &anticoagulant ttt. </li></ul>
    37. 38. Q- What is Door needle time mean in treatment of stroke? <ul><li>If the pt. present within 1 st 3 hour “befor cytotoxic oedema formation” We can give Thrombolysis after exclude haemorrage & We can give Asprin safty, the best thrombolytic is => t.PA ( S/E: increase haemorrage size) </li></ul><ul><li>If the source of thrombosis: </li></ul><ul><li>Inside heart=> warferin </li></ul><ul><li>Outside heart=> asprin 300mg crushed immediately, Endartrectomy => if carotid 70% occluded. </li></ul>
    38. 39. <ul><li>Q- if the lesion? </li></ul><ul><li>In middle cerebral artery:- Weakness in arm & face > leg. </li></ul><ul><li>In Anterior cerebral artery:- Weakness in leg > arm & face. </li></ul><ul><li>Q- what is the prognosis of TIA? ( ROLE OF 30%) </li></ul><ul><li>30% will develop nothing </li></ul><ul><li>30% will develop TIA within 2 years </li></ul><ul><li>30% will develop TIA within 6 month& 30% of them will die </li></ul><ul><li>  </li></ul>
    39. 40. Thank you for your attention Now start of OSCE…..
    40. 41. Best whishes أليس الماضي و عبق التاريخ يا رمز النضال لؤلؤة النيل حورية الضفاف باهية الجمال هواك يناديني فأهرع عبر المدائن و البوادي و التلال
    41. 44. BRAIN ABSCESS
    44. 47. <ul><li>ASSESS GRADES OF BEST MOTOR RESPONSE (Max score 6) </li></ul><ul><li>6 Carrying out request ('obeying command') </li></ul><ul><li>5 Localizing response to pain. </li></ul><ul><li>4 Withdrawal to pain - pulls limb away from painful stimulus. </li></ul><ul><li>3 Flexor response to pain - pressure on nail bed causes abnormal flexion of limbs </li></ul><ul><li>2 Extensor posturing to pain - stimulus causes limb extension </li></ul><ul><li>1 No response to pain. </li></ul>The Glasgow coma scale (GCS)
    45. 48. <ul><li>  ASSESS GRADES OF BEST VERBAL RESPONSE (Max score 5) </li></ul><ul><li>5 Oriented - patient knows who & where they are, and why, and the year, season & month. </li></ul><ul><li>4 Confused conversation - patient responds in conversational manner, with some disorientation and confusion. </li></ul><ul><li>3 Inappropriate speech - random or exclamatory speech, no conversational exchange. </li></ul><ul><li>2 Incomprehensible speech - no words uttered, only moaning. </li></ul><ul><li>1 No verbal response. </li></ul><ul><li>  </li></ul>Cont
    46. 49. <ul><li>EYE OPENING (Max score 4) </li></ul><ul><li>4 Spontaneous eye opening. </li></ul><ul><li>3 Eye opening in response to speech - that is, any speech or shout. </li></ul><ul><li>2 Eye opening in response to pain. </li></ul><ul><li>1 No eye opening. </li></ul><ul><li>TOTAL SCORE ...... / 15 RECORD YOUR FINDINGS You may record you findings on a specific ‘CNS’ chart. Otherwise record in the following fashion:   </li></ul>Conti
    47. 52. UMN Vs LMN <ul><li>UMN – contralateral facial weakness with forehead sparing </li></ul><ul><li>LMN – ipsilateral facial weakness with no forehead sparing </li></ul>
    48. 53. Bell’s Palsy <ul><li>Acute LMN nerve palsy </li></ul><ul><li>Unilateral </li></ul><ul><li>Inflamed facial nerve within petrous temporal bone </li></ul><ul><li>24 hx ear ache </li></ul><ul><li>No sensory loss </li></ul><ul><li>Idiopathic </li></ul><ul><li>?HSV – acyclovir – inconclusive evidence </li></ul><ul><li>?short course high dose steroids </li></ul>Worth learning a differential for facial weakness: Acoustic neuroma Bell’s Palsy Middle ear infection Ramsay-Hunt syndrome Parotid gland tumours Mumps Guillain-Barre Mononeuritis multiplex MS MND
    49. 54. What is this Condition? Ramsay Hunt Syndrome
    50. 55. Cerebellar Examination <ul><li>Coordination </li></ul><ul><li>Intention Tremor </li></ul><ul><li>Finger nose test </li></ul><ul><li>Gait </li></ul><ul><li>Heel Knee Test </li></ul><ul><li>Dysdiadokokinesis </li></ul><ul><li>Nystagmus </li></ul>
    51. 56. Power Grading (Medical Research Council Scale) <ul><li>0 No movement </li></ul><ul><li>Flicker of movement </li></ul><ul><li>Movement but not against gravity </li></ul><ul><li>Movement against gravity but not resistance </li></ul><ul><li>Weak movement against resistance </li></ul><ul><li>Normal </li></ul>
    52. 57. Upper motor neuron lesion <ul><li>Stroke (hemiplegia), cerebral palsy, MS (spastic paraplegia) </li></ul><ul><li>No muscle wasting </li></ul><ul><li>Pyramidal weakness </li></ul><ul><li>Upper limb – weak abductors and extensors (flexed) </li></ul><ul><li>Lower limb – weak adductors and flexors (extension) </li></ul><ul><li>Increases tone (spasticity/ clasp knife) </li></ul><ul><li>Hyperreflexia and clonus. Upgoing plantar. </li></ul><ul><li>Circumductive gait </li></ul>
    53. 58. Peripheral neuropathy <ul><li>Usually generalised (diabetic), mononeuropathy (medicn nerve) or radiculopathy </li></ul><ul><li>Distal sensory or motor and sensory loss </li></ul><ul><li>Inspection - Pes cavus, wasting, fasciculation,clawing </li></ul><ul><li>Tone – decreased </li></ul><ul><li>Power – distal weakness </li></ul><ul><li>Reflexes – Reduced/ absent </li></ul><ul><li>Sensory – glove and stocking loss / paraesthesia </li></ul><ul><li>Disease affecting pathology of the peripheral nerves may be perfectly normal/ proximal weakness (Guillain- Barre syndrome) </li></ul><ul><li>Eg Charcot- Marie-Tooth, </li></ul>
    54. 61. Retina Optic Nerve LGB Optic radiation Chiasma Lower fibres (Temp lobe) Upper fibres (ant parietal lobe) Occipital Cortex
    55. 62. Retina Optic Nerve LGB Optic radiation Chiasma Lower fibres (Temp lobe) Upper fibres (ant parietal lobe) Occipital Cortex
    56. 63. Retina Optic Nerve LGB Optic radiation Chiasma Lower fibres (Temp lobe) Upper fibres (ant parietal lobe) Occipital Cortex
    57. 64. CN II:
    58. 65. Optic Nerve Lateral Geniculate Body Pretectal Nucleus Edinger – Westphal Nucleus of III Convergence Centre Cilliary Ganglion Cilliary Body - Iris Afferent Pathway Efferent Pathway
    59. 67. Extra Ocular Eye Muscles
    60. 69. Signs of right third nerve palsy <ul><li>Ptosis, mydriasis and cycloplegia </li></ul><ul><li>Abduction in primary position </li></ul><ul><li>Limited depression </li></ul><ul><li>Limited adduction </li></ul><ul><li>Normal abduction </li></ul><ul><li>Limited elevation </li></ul><ul><li>Intorsion on attempted </li></ul><ul><li>downgaze </li></ul>
    61. 71. Important causes of isolated third nerve palsy Idiopathic - about 25% Vascular disease - hypertension, diabetes Posterior communicating aneurysm Trauma Extradural haematoma Prolapsing temporal lobe Edge of tentorium Aneurysm Chiasm Third nerve Posterior cerebral artery Midbrain pushed across
    62. 72. Horner’s Syndrome <ul><li>Ptosis </li></ul><ul><li>Miosis </li></ul><ul><li>Anhydrosis </li></ul><ul><li>Enopthalmos </li></ul><ul><li>Lesion to cervical/sympathetic chain </li></ul><ul><li>EXAMS: Horner’s syndrome = pancoast tumour </li></ul><ul><li>BUT ptosis does not = horner’s </li></ul><ul><li>Could be CN III lesion </li></ul>
    63. 73. Anatomy of fourth nerve <ul><li>Only cranial nerve to emerge dorsally </li></ul><ul><li>Crossed cranial nerve </li></ul><ul><li>Very long and slender </li></ul>Internal carotid artery Postr. communicating artery III VI Postr.cerebral artery Supr.cerebellar artery Basilar artery IV
    64. 74. Signs of right fourth nerve palsy <ul><li>Right overaction on left gaze </li></ul><ul><li>Right underaction on depression </li></ul><ul><li>in adduction </li></ul><ul><li>Vertical diplopia </li></ul><ul><li>Right hyperdeviation in primary </li></ul><ul><li>position when left eye fixating </li></ul><ul><li>Excyclotorsion </li></ul>slightly upwards and outwards (extorsion)
    65. 75. Recent right sixth nerve palsy Right esotropia in primary position due to unopposed action of right medial rectus Marked limitation of right abduction due to right lateral rectus weakness
    66. 76. Hess chart of recent right sixth nerve palsy <ul><li>Contraction of right chart and expansion of left </li></ul><ul><li>Right chart - marked underaction of lateral rectus and mild overaction of medial rectus </li></ul><ul><li>Left chart - marked overaction of medial rectus </li></ul>
    67. 77. Left VI Nerve Palsy (lateral Rectus)
    68. 78. CN V: Trigeminal Nerve <ul><li>Sensory </li></ul><ul><ul><li>Patient eyes closed </li></ul></ul><ul><ul><li>Cotton wool </li></ul></ul><ul><ul><li>Touch each division left and right </li></ul></ul><ul><ul><li>Compare each side </li></ul></ul><ul><ul><li>Corneal reflex – not normally done! </li></ul></ul><ul><li>Motor </li></ul><ul><ul><li>Ask patient to clench teeth </li></ul></ul><ul><ul><ul><li>Temporalis </li></ul></ul></ul><ul><ul><ul><li>masseter </li></ul></ul></ul><ul><li>Jaw jerk </li></ul><ul><ul><li>Not normally done! </li></ul></ul><ul><ul><li>Checking for UMN lesion (brisk reflex) </li></ul></ul>
    69. 80. CN VIII: Vestibulo-cochlear <ul><li>“ noticed any change in hearing?” </li></ul><ul><li>Hearing: </li></ul><ul><ul><li>Block other ear </li></ul></ul><ul><ul><li>Rubbing fingers together, see when they can no longer hear it </li></ul></ul><ul><li>Rinne’s – tuning fork louder in front or behind? </li></ul><ul><li>Weber’s – is it louder in one ear? </li></ul>
    70. 82. CN IX: Glossopharyngeal <ul><li>Sensory: post 1/3 rd of tongue (facial nerve ant 2/3 rd ) </li></ul><ul><li>Motor: stylopharyngeus </li></ul><ul><li>Autonomic: salivary glands </li></ul><ul><li>Inspect: </li></ul><ul><ul><li>Position of uvula </li></ul></ul><ul><li>“ say aahh” </li></ul><ul><ul><li>See if the uvula deviates to one side (away from abnormal side) </li></ul></ul>
    71. 83. CN XI: Accessory Nerve <ul><li>Inspect neck: </li></ul><ul><ul><li>Sternomastoid wasting/fasciculation </li></ul></ul><ul><ul><li>Shoulders equal? </li></ul></ul><ul><li>Put you hand on side of face and say “push against my hand” </li></ul><ul><li>Test each shoulder separately: </li></ul><ul><ul><li>Shrug your shoulder against my hand” </li></ul></ul><ul><li>UMN: ipsilateral sternomastoid and contralateral trapezius wasting </li></ul><ul><li>LMN: ipsilateral sternomastoid and trapezius wasting </li></ul>
    72. 85. CN XII: Hypoglossal Nerve <ul><li>Inspect tongue (resting inside mouth) </li></ul><ul><ul><li>Wasting, fasciculations </li></ul></ul><ul><li>Stick your tongue out: </li></ul><ul><ul><li>Watch if is deviates to one side: </li></ul></ul><ul><ul><ul><li>Weakness on the side it deviates to </li></ul></ul></ul>
    73. 86. <ul><li>Representative of Case History #2 </li></ul><ul><li>Guillain-Barré Syndrome (GBS) </li></ul><ul><li>acute inflammatory demyelinating polyneuropathy </li></ul><ul><li>disorder of the peripheral nerves </li></ul><ul><li>attack of the myelin sheath of nerves by antibodies or white blood cells </li></ul><ul><li>rapid onset of ascending paralysis </li></ul><ul><li>begins with weakness and/or abnormal sensations of the legs and arms </li></ul><ul><li>breathing muscles may be so weakened </li></ul><ul><li>following gastrointestinal or respiratory viral infections </li></ul><ul><li>palpitations (sensation of feeling heartbeat), difficulty beginning to urinate, incomplete bladder emptying, incontinence (leaking of urine), constipation, and muscle contractions </li></ul>
    74. 87. Representative of Case History #1 DUCHENNES MUSCULAR DYSTROPHY Gower’s Sign <ul><li>marked enlargement of calves </li></ul><ul><li>hyperlordosois </li></ul><ul><li>decreased tendon reflexes </li></ul><ul><li>normal sensation </li></ul>
    75. 88. The end….. <ul><li>Thank You!! </li></ul>Be the change ,which you want to see in the World