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Neurology

Neurology

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Print Preview Chapter 11 Neurologic DisordersKerri Kissel Neil Porter I. Approach to the Patient with a Neurologic ComplaintA. Patient historyThe patient history is the cornerstone of neurologic assessment.
y
 
1. Key questions. Questions that may help direct the patient interview include:
o
 
a. Was the onset of symptoms gradual or sudden?
o
 
 b
. Are the symptoms static, intermittent, or progressive?
o
 
c. Has the pro
 b
lem remained limited in scope, or have new features
 b
een introduced over time?
o
 
d. What concurrent pro
 b
lems does the patient have, and whatmedications or drugs are
 b
eing used?
o
 
e. Is there a family history of the disorder or predisposing conditions?
o
 
f. What ha
 b
its and toxin exposures might the patient have?
y
 
2
. Review of symptoms. Depending on the clinical complaint, a patient should
 b
e asked whether there is any history of:
o
 
a. Headache or trauma to the head, neck, or spine
o
 
 b
. Loss of consciousness, convulsive activity, mood alterations,confusion, or memory distur 
 b
ances
o
 
c. Impaired or dou
 b
le vision, facial num
 b
ness or weakness, impairedhearing or swallowing, or a
 b
normal speech
o
 
d. Arm or leg weakness or heaviness, slowness of movement, alteredlim
 b
sensation, discomfort or tingling in the extremities
o
 
e. Clumsiness, falling, or dizziness
o
 
f. Bowel or 
 b
ladder distur 
 b
ances or sexual dysfunctionB. Neurologic examinationFrom the patient history, the physician can generate a series of diagnostic hypothesesthat can
 b
e tested with a focused neurologic examination. Anatomic localization of the pathology within the nervous system is essential to this process (Figure 11-1).
y
 
1. Mental status. If the patient's mental status is a
 b
normal, the history andthose components of the physical examination that depend on patientcooperation must
 b
e approached within the proper context. For example, if the patient is confused, the sensory examination may
 b
e unrelia
 b
le.
o
 
a. The patient's level of arousal, orientation, short- and long-termmemory, affect (i.e., mood), concentration and attention, fund of knowledge, insight, judgment, and constructional a
 b
ility should
 b
eassessed.
o
 
 b
. Linguistic a
 b
ilities are evaluated
 b
y examining comprehension,repetition, fluency, naming, reading, and writing.
o
 
c. The integrity of other cortical functions (e.g., graphesthesia,stereognosis, two-point discrimination, right±left orientation, andneglect) should
 b
e examined if parietal lo
 b
e dysfunction is suspected.
y
 
2
. Cranial nerves. Examination of cranial nerves II±XII is necessary (Ta
 b
le11-1).
 
o
 
a. In par 
til
ar, v
i
a
l
acu
it
and f 
il
ds shou
l
d e checked;
t
he op
ti
cnerve shou
l
d e exam
i
ned; and anorma
liti
es of ocu
l
ar mo
tilit
,
i
nc
l
ud
i
ng nys
t
agmus and dysme
t
i
a, shou
l
d e documen
t
ed (Ta
l
e 11-).
o
 
 b
. A
 b
norma
liti
es of fac
i
a
l
sensa
ti
on (
i
nc
l
ud
i
ng
t
he cornea
l
ref 
l
ex) andmovemen
t
a
l
so shou
l
d
 b
e
i
nves
ti
ga
t
ed.V
i
ew F
i
gure FIGU
11-1 Summary of some of 
t
heou
t
s
t
and
i
ng neuro
l
og
i
c s
i
gns and symp
t
oms
t
ha
t
occur w
it
h foca
l
des
t
ruc
ti
ve
l
es
i
ons
i
n
t
he r 
i
gh
t
or 
l
ef 
t
cere
 b
ra
l
hem
i
sphere asde
t
ec
t
ed on neuro
l
og
i
c exam
i
na
ti
on. (A)La
t
era
l
v
i
ew of 
t
he
l
ef 
t
cere
 b
ra
l
 hem
i
sphere. (
B
) La
t
era
l
v
i
ew of 
t
he r 
i
gh
t
 cere
 b
ra
l
hem
i
sphere. (
epr 
i
n
t
ed from N
M
S Neuroana
t
omy.
M
a
l
vern, PA
:
Harwa
l
 Pu
 b
li
sh
i
ng, 1988
:3
14).
TABLE 11-1 Twelve Cranial NervesCN Nerve Function
I O
l
fac
t
ory Sme
ll
 II Op
ti
c V
i
s
i
onIII Ocu
l
omo
t
or Eye movemen
t
sIV Troch
l
ear Eye depress
i
on (when adduc
t
ed)V Tr 
i
gem
i
na
l
Fac
i
a
l
sensa
ti
onVI A
 b
ducens Eye a
 b
duc
ti
onVII Fac
i
a
l
Fac
i
a
l
movemen
t
 VIII Ves
ti
 b
u
l
ococh
l
ear Hear 
i
ngIX G
l
ossopharyngea
l
Pa
l
a
t
a
l
sensa
ti
onX Vagus Pa
l
a
t
a
l
movemen
t
 XI Sp
i
na
l
accessory Shou
l
der shrugXII Hypog
l
ossa
l
Tongue pro
t
rus
i
on
C
 N, cran
i
a
l
nerve.
TABLE 11-2 Innervation of the Eye by Its Six NervesNumber andName of NerveInnervation Clinical Effects of Interruption of NerveEfferent
 
C
 N III(ocu
l
omo
t
or nerve)S
t
i
a
t
ed musc
l
e
:
super 
i
or,med
i
a
l
, and
i
nfer 
i
or rec
ti
;
i
nfer 
i
or o
 b
li
ueLeva
t
or pa
l
 pe
 b
raeD
i
 p
l
op
i
a, eye a
 b
duc
t
ed and
t
urned downP
t
os
i
s (para
l
ys
i
s of vo
liti
ona
l
 
li
d e
l
eva
ti
on)
 
S
mooth muscle: pupilloconstrictor Ciliary musclePupil dilated and fixed to lightLoss of lens thickeningCN IV(trochlear nerve)
S
triated muscle: superior o
 b
liqueDiplopia, most severe onlooking down and in
;
eyeextorted
;
head tilted to sideopposite paralyzed eyeCN VI(a
 b
ducensnerve)
S
triated muscle: lateralrectuusDiplopia, most severe onlooking to side of paralysis
;
eyeturned in (adducted)Carotidsympatheticnerve
S
mooth muscle
;
superior tarsal and pupillodilator Horner's syndrome (ptosis,miosis, hemifacial anhidrosis,vasodilation)
Afferent
 CN II (opticnerve)From retina BlindnessCN V(trigeminalnerve)Corneal/conjunctival afferents Anesthesia of cornea with lossof corneal reflexAdapted from NM
S
 
 Neuroanatomy.
Malvern, PA: Harwal Pu
 b
lishing,1988:
2
19.
y
 
3
.
S
ensory system. Regions of a
 b
normal touch, pain (estimated
 b
y pinprick),temperature, vi
 b
ration, and proprioception should
 b
e defined.
o
 
a. Are the findings confined to one side of the
 b
ody, the distri
 b
ution of one or more dermatomes, or the territory of one or more peripheralnerves?
o
 
 b
. Are the sensory changes found in a ³stocking±glove´ distri
 b
ution?
y
 
4
. Motor system
o
 
a. The patient's strength should
 b
e defined as it pertains to individualmuscles or groups of muscles. One conventional method of gradingmuscle strength for purposes of comparison and description is showninTa
 b
le 11-
3
.
o
 
 b
. A pronator drift can
 b
e assessed
 b
y having patients extend their arms(palm upward) with their eyes closed. Any depression or pronation issignificant.
o
 
c. The presence of atrophy, fasciculations, spasticity, and rigidityshould
 b
e noted.
o
 
d. The patient's a
 b
ility to perform rapid alternating and other complexmaneuvers should
 b
e determined.
o
 
e. The patient's stance and gait should
 b
e evaluated.
y
 
5
. Coordination. Finger-to-nose and heel-to-shin testing should
 b
e performed.The physician should look for Rom
 b
erg's sign (i.e., swaying or falling whenstanding with eyes closed and feet close together).
y
 
6
. Muscle stretch reflexes. The activity and symmetry of the
 b
rachioradialis(C
5
, C
6
),
 b
iceps (C
5
, C
6
), triceps (C7, C8), knee (L
3
, L
4
), and ankle (
S
1,
S
2
)reflexes should
 b
e determined. The presence of the Ba
 b
inski response should
 b
e assessed with plantar stimulation.

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dr cannot find cause been evereywherein memphis,tn,done allblwk,ctscan3x,fine,2botox(worse,they have gave up ,been on all type of meds nothing helped.could be mymed but other places says no,because been on it so long & try to get dw & change & did not help at all prob worse.these ha's are spreading,worring me,i cann't get any help jusy lost my life againg pleae pray for me.GOD IS MY ONLY ANSWER!
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past 2yrs orso been having chronic daily ha,s,worse lying dw,usually start around 9am on off till bedtill keep ice pk on ha allday go to bed with ice pk on ha with ice pk on ha. if take something to relax it ease up for 1hr maybe then rg bk but worse in evening get hot flashes eyeshurtbadly top of pressure exploding to rg side(tingling&numb)bktobkofskull times fels like going tofall out dr cannt
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