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VI

EXAMINATION OF
CEREBELLAR FUNCTION

Cerebellum is located in the post cranial fossa


and coordinates MM movement & maintains
bpdy equilibrium and MM. tone.
Diseases produce ataxia; intention tremor
nystagmus; dysmetria; dysdiadochokinesia;
hypotonia; rebound.
Testing for abnormalities of coordinated
movements of upper limbs asking pt. to
extend arms for ward 90 with forearms &
hands supinated.
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Pt. closes eyes, maintains position


w i t h o u t mo ve me n t: ob se r ve f o r
slowdrift of one of the upper limbs
consisting of slow pronation & gradual
descent of the affected limb. Drifting
maybe seen with minimal weakness of
af fected limb or sensor y
(propioceptive) impairment of the limb.
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REBOUND
- Maybe tested by depressing one of the
extended limbs & releasing it rapidly. The
extended arm of the intact individual will
immediately reassume the intial position but
the arm of the pt. with cerebellar dis. will
make
several oscillations of decreasing
amplitude before it assumes resting position.
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RAPID ALTERNATING SUPINATIONPRONATION of extended forearms


and hands --- slowing and
overflinging in cerebellar disease.

FINGER TO NOSE TEST


Examiner holds his extended index finger
at arms length from the patient. The
patient is asked to touch the finger then
touch his nose. In cerebellar dis. There is
past-pointing with the pts index finger
repeatedly overshooting the target and
intention tremor.
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TESTS FOR LOWER LIMBS


HEEL TO SHIN TEST
Patient slides the heel of one lower limb down the
anterior tibial surface of the other.
TOE TAP TEST
The pt. taps the patella of one extremity with the
toes of the other.
FOOT TAPPING TEST
- Pt. stands with one foot placed forward and slightly
to the side, rests the heel on the floor and rapidly
taps the floor with the toes.
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VII.
EXAMINATION OF SENSORY
FUNCTION

Concerned with appreciation of primary


or cutaneous sensation and evaluation of
cortical integration of sensory impluses.
Examination begins with evaluation of
LIGHT TOUCH wisp of cotton applied
lightly to the skin. Pt. closes the eyes and
is instructed to say yes when the
stimulus is appreciated.
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PAIN SENSATION
Tested with a corsage pin or pinwheel moved bet ween
distal and proximal areas. Two sides of the body are
compared and pt. is asked for any difference or any
change as the pin is moved.
VIBRATION SENSE
- Placing the base of the tuning fork over a bony
prominence and instructing the pt. to indicate when the
sensation of vibration is no longer appreciated. Vibration
is decre ased when the e xaminer appreciate s the
continuation of vibration that is no longer appreciated
by the pt.
- Should be equal on the 2 sides of the body.
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POSITION SENSE OR PROPRIOCEPTION


Tested by moving gently a terminal phalanx in an
upward or downward direction while the pt. is
instructed to close the eyes and indicate whether
the digit is moved up or down.
TEMPERATURE SENSATION
- Evaluated by application of glass tubes filled
with hot or iced water to the skin in a random
fashion and alternately to each side of the body
and pt. is asked to identify whether the stimulus is
hot or cold.
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DISCRIMINATION OF TACTILE STIMULI


A cortical function evaluated by testing: tactile
localization, extinction, t wo-point descrimination,
graphism; stereognosis
TACTILE LOCALIZATION
Tested by asking the pt. to close the eyes and to name
the body part that is touched with a piece of cotton.
Patient is then touched at an identical site in both
sides of the body at the same time. Normally, pt. will
appreciate both sides of stim. With parietal lobe
lesion.

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Pt will appreciate only one stimulus and will fail to


appreciate the stimulus applied to the side opposite the
lesion.
>

TWO-POINT DESCRIMINATION
Tests the ability of the pt to differentiate one stimulus
from 2 impaired in parietal lobe lesion.
STEREOGNOSIS
Ability to identify objects placed in the palm.
GRAPHISM
Ability to identify numbers written on finger pads of
terminal phalanx
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VIII.
EXAMINATION OF REFLEXES

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Reflexes are of three types


STRETCH
SUPERFICIAL
RELEASE
JAW JERK
- Obtained by placing the examining index finger in the
midline on the pts jaw and asking pt to open the mouth
about 30 and then to relax. Examiner strikes index
finger with neurologic hammer produces stretching of
masseter & pterygoid MM then contraction of these
MM and jaw jerks towards a closed position.

Often absent in normal individual or may be present


with minimal movement of the jaw
Exaggerated in corticobulbar tract lesions above the
midpons
Imprtant since it is the highest stretch reflex that can
be elicited in the neuro-exam
Upper jaw jerk means the lesion is above midpons. A
normal jaw jerk with higher stretch reflexes in the
upper limb indicate lesion below the pons but above C5.

Four Primary Stretch


Reflexes
REFLEX

ROOTS NEEDED FOR THE REFLEX

Triceps Surae

S1

Quadriceps-Femoris

L2, L3, L4

Biceps

C5, C6

Triceps

C7, C8

Reflexes are usually graded on


a 0 to 4+ scale

No response

1+

Somewhat diminished; Low normal

2+

Average; Normal

3+

Brisker than average; possibly but not


necessarily indicative of disease

4+

Very brisk; hyperactive; often indicative of


dis; often associated with clonus.

SUPERFICIAL REFLEXES
Elicited by applying gentle pressure to the skin in a
specific area.
ABDOMINAL REFLEX
Stroking the skin of abdomen gently with a blunt
object in a diagonal fashion toward the midline. The
abdominal MM contract below stimulus under
normal circumstances
Absent on the side of CST lesion
Difficult to observe in obese individual

CREMASTERIC REFLEX
Obtained in the male by stroking the ant.
Medial aspect of the thigh with a blunt object.
Results in contraction of the cremasteric MM
and elevation of the testicles of the same side
lost in CST lesions and in lesions involving
lower segments of the spinal cord.

ANAL REFLEX
Produced by gently stroking the skin around the anal
margin which produces contraction of the anal
sphincter
Lost in lesions involving sacral segments of spinal
cord and cauda equina
PLANTAR RELFEX
- Elicited by stimulation of the lateral aspect of the
sole of the foot with a blunt object. Movement is
carried along the lateral aspect of the sole then
across the head of the metatarsal bones.

> Produces flexion of the big toe which is a normal


plantar flexion responses.
The babinski response consists of extension of the big
toe and extension of the other toes which separate
in a fan like fashion.
RELEASE REFLEXES
- Reflexes responses present in the new born infant.
Disappear with maturation of the CNS but can
reappear in degenerative dis. Associated with loss of
inhibitory activity in the brain.

GLABELLAR REFLEX
Elicited by gently tapping the forehead in the
midline just above the bridge of the nose. Under
normal circumstances this produce rhythmic
contraction of the eyelids which disappear
after a few seconds.
Abnormal response: persistent closure of the
eye and blepharospasm in response to each
stimulus. Indicative of degenerative dis. Of the
brain alzheimers dis; parkinsons dis; frontal
lobe infarction and frontal lobe tumor.

SNOUT REFLEX
Elicited by tapping the face bet ween the upper
lip and the nose gently with the finger.
There is pursing of the lips in response to each
stimulus
Cant be elicited in normal individuals. Appears
in pts with bilateral cerebral damage often
associated with pseudobulbar palsy.

SUCKING REFLEX
Stroking gently the upper or lower lip fr the midline
to the lateral border of the month with the finger
or tongue blade, lips cont ract in a sucking
movement.
Normally present in infant . Reappears in diffuse
dis. Of the brainalzheimers dis and other
dementias.

CHEWING REFLEX
An abnormal response obtained by placing a tongue
blade in the mouth. Pt begins to make chewing
movements and the jaws may bite down on the tongue
blade and make removal difficult bulldog responseindicative of diffuse bilateral cerebral hemispheric
lesions.

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GRASP REFLEX
Obtained by stimulating the palm of the pts
hands stroking the palm with examiners
fingers. Positive when the pts fingers flex and
grasp examiners fingers grasp maybe sustained
and release of the grasp can be accomplished by
gently stroking the dorsal surface of the pts
hands.
Indicative of diffuse bilateral dis. Involving
cerebral hemisphere, commonly dementia.

IX.
EXAMINATION OF
PERIPHERAL PULSES

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- Radial pulses should be of equal volume


at the wrist.
Dorsalis pedis and posterior tibial pulses
should be palpable in the feet.
If peripheral pulses in the feet are
a b s e n t, au s c u l t a t i o n o f f e mo r a l
arteries for bruits be done- in cases of
peripheral vascular dis. Which often
accompany cerebrovascular dis.
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AUSCULTATION FOR BRUITS


Auscultation is carried over the carotid
arteries during general physical exam for
bruits after the heart has been evaluated &
examined.
Auscultation over the eye for intracranial
bruits by using the bell of the stethoscope
placed over the closed eyelid.
Associated with arteriovenous malformation
and severe stenosis of the carotid arteries.
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X.
EXAMINATION OF
HEAD NECK AND SPINE

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NUCHAL RIGIDITY
>Examiner asks the pt to flex the head and place
the chin on the chest; nuchal rigidity is positive
when there is resistance to flexion positive,
other movements of the neck are free.
BRUDZINSKI SIGN
>Consists of flexion of the knee when the head
is flexed on the chest.
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KERNIGS SIGN
Characterized by back pain and sciatic pain on
attempting to straighten the leg when the thigh is
flexed at the hip.

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EXAMINATION OF PERIPHERAL NERVES


Palpation of P.N. carried out in all cases of
suspected peripheral neuropathy
Ulnar N. easily palpated In the ulnar groove
medial aspect of elbow jt.
Common peroneal n. can be felt as it winds
around the head of the fibula.
Enlargement of nerves occurs in some cases of
chronic peripheral neuropathies.
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EXAMINATION OF THE SPINE


Short cer vical spine with low head line
indicates congenital abnormalities of skull
baseplatybasia or odontoid compression
Limitation of cervical spine movements due to
cer vical spondylosis
Scoliosis a fe ature of spinocerebellar
degeneration, poliomyelitis, trauma
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Kyphosis
-is a cur ving of the spine that causes a bowing or rounding of
the back, which leads to a hunchback or slouching posture.
Lordosis
-abnormally increased inward curvature of the lower region of
the spine resulting in a concave back as viewed from the side
Gibbus deformity
-is a form of structural kyphosis, where one or more adjacent
vertebrae become wedged. Gibbus deformity can be a sequela of
advanced skeletal tuberculosis and is the result of collapse of
vertebral bodies. This can in turn lead to spinal cord compression
causing paraplegia.
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END OF LECTURE
THANK YOU! = )

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