3Neurological examination

Health Assessment

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The neurologic examination is a systematic process that includes a variety of clinical tests. observations. . and assessments designed to detect abnormities in neurologic functioning .

• Thus.• The brain and spinal cord cannot be examined as directly as other systems of the body. much of the neurologic examination is an indirect evaluation that assesses the function of the specific body part or parts controlled or innervated by the nervous system. .

A neurologic assessment is divided into five components: o cerebral function o cranial nerves o motor system o sensory system o and reflexes. o In addition to Vital signs .

•Equipment –Eye charts – tuning fork –pen light –reflex hammer –Key & coin. –Cotton –Others . –big safety pin.

bradycardia .change V/S can also accompany the late stages of increased ICP.pt who have cervical spinal cord injuries may have hypotension. . . Vital signs:.

 Assessing Cerebral Function. -Cerebral abnormalities may cause disturbances in mental status .

and language and communication . • consciousness (awareness of self and environment) Level of consciousness (LOC).ect. mood. is most sensitive indicator of changes in neurologic status. ..Mental Status • Examine LOC. memory.

*Tool assess LOC. an international scale used to assess level of consciousness (LOC) . Glasgow Coma Scale. .

 Verbal response. .  Motor response.The GCS assesses three parameters of consciousness:  Eye opening.

Scoring: –Eye opening Spontaneous: 4 To speech: 3 To pain: 2 No Response: 1 .

– Best Verbal Response  Oriented : 5  Confused : 4  Inappropriate words :3  Incomprehensible sounds : 2  No Response: 1 .

Best Motor Response:  Obeys commands : 6  Localizes pain : 5  Withdraws to pain: 4  Abnormal Flexion (Decorticate): 3  Abnormal Extensor (decerebrate): 2  No Response: 1 .

decortication .

decerebration .

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Interpretation of GCS : – Total: 3-15 – Minor LOC: 13-15 – Moderate LOC: 9-12 – Severe/deep coma : <= 8 .

Speech and Language Aphonia . abnormal production of sound from larynx assess . soft. . defects in articulation and rhythm in speech . whispered  dysarthria . Assess by ask the pt to repeat a diffcult phrase. is patient`s voice hoarse.

.Aphasia. assess write word and ask pt to read. inability to recognize objects by means of senses. inability to use and understand written and spoken words. Agnosia.

Thought Processes and Perception • Perceptions – Illusions/delusions – Hallucinations • Ability to make a decision/judgment • Insight .

repeat 3-4 unrelated word (wait) • Remote memory (days-yrs) – Ask BD. favorite President • Abstract reasoning skills – Meaning of a proverb. last President.Cognitive Abilities and Mentation • Immediate (sec-min) – Ask to repeat 3-4 unrelated words • Recent memboy (min-hrs) – Ask who “I” am. anniversary. last visitor. auditory. last meal. simple math • Interpretation of stimuli – Visual. tactile .

Cranial Nerves examination I(S) Olfactory II(S) Optic III(M) smell vision Oculomotor pupil constriction. light reflex IV(M) Trochlear uvula movement . lid elevation.

raise hearing. smile. lateral eye movement VII(B) Facial eyebrows. equilibrium .V(B) Trigeminal sensation of scalp & (corneal reflex). mastication VI(M) Abducens face. taste VIII(S) Acoustic lid closure.

gag.IX(B) X(B) XI(M) Glossopharyngeal Vagus swallow. XII(M) swallow. laryngeal sounds. ROM of tongue . say “ahh” Spinal accessory shoulder & neck movement Hypoglossal symmetrical tongue.

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Motor System  includes an assessment of muscle: • size • tone • and strength  coordination. . and balance The pt is instructed to walk across the room while the examiner observes posture and gait.

fluid. rate size of steps. feet clear floor. client will watch feet . finger to nose. posture.Motor System (Cerebellum) • Coordination – Ataxia – rapid alternating hand/foot tap (RAM). finger to finger • Gait and Balance – Heel-toe walk (Tandem test). Romberg test.

dislocation of hips. MS. rigid body • Scissors – knees cross/in contact. alcohol (barbiturate) • Parkinsonian – basal ganglia defects. stooped posture. staggering. CP • Steppage/footdrop – lower motor neuron defect • Waddling – MD. immobile arm against body.Gait Abnormalities • Spastic hemiparesis – stroke. short/shuffling steps. lordosis & protruding abdomen Short leg – >1inch . trunk forward. toe drag • Cerebellar ataxia – loss of position sense. stiff/extended leg.

Motor System • Muscle size. push/pull arms and legs (0-5 scale). strength. tremors or fasciculation • Tremor differentiation – “When does it occur?” – Table 23-4 (p. note tics. tone bilaterally – Grip. palpate muscle size bil. 703-704) .

“pill rolling” • Intention – Worse with voluntary movement. improves with sedative/alcohol – benign .Tremors • Fasciculation – Rapid. often with emotional stress. MS. falling asleep. disappears with voluntary movement. Essential (older adults). hiccup. sudden jerk. fine (atrophy/weakness) or coarse (cold/fatigue) • Tic – Repetitive twitching • Myoclonus – Rapid. continuous twitching of resting muscle/part of muscle. grand mal seizure • Resting (static) – Coarse & slow.

jerky. rapid. disappears with sleep. writhing. continuous movement (snake/worm like). CP . twisting. disappears with sleep. purposeless movement.Tremors continued • Chorea – Sudden. Huntington’s • Athetosis – Slow.

summation effect. extinction. graphesthesia.Sensory Assessment • Exteroceptive sensation – Light touch. point location . position. vibration • Cortical sensation – Sterognosis. cold) • Proprioceptive sensation – Motion. temperature(hot. superficial pain (sharp/dull). twopoint discrimination (2-3 mm is normal).

.Light Touch • Client sitting • Eyes closed • “Say where you are touched. and distally to proximally.” • Compare bilaterally.Exteroceptive sensation 1.

• 2. Superficial pain • 3.temperature(hot.. cold) .Exteroceptive sensation cont.

Proprioceptive sensation 1.Vibratory Sensation • Close eyes • Strike fork & start on most distal bony prominence & work medially with neuropathy • Ask when do you feel the vibration start and when do you feel the vibration stop. .

Stereognosis • Close eyes • Place object in hand • “Identify object.” • Test bilaterally with different objects. • Note speed and accuracy • Astereognosis – unable to identify object .Cortical sensation 1.

Cortical sensation cont...Graphesthesia (Parietal Lobe) • Close eyes • Draw letter or number on hand • “Identify figure. 2.” • Test bilaterally • Note speed and accuracy • Agraphesthesia – inability to identify figure .

Cortical sensation cont...
3.two-point discrimination 4. point location

Reflexes
• Rapid involuntary predictable motor response to a stimulus. Reflex arc, is not dependent on the brain. • Somatic
– Skeletal muscle contraction

• Autonomic
– Cardiac, smooth muscle and glands

Reflexes
• Deep tendon
– Grading scale 0-4+ – Compare bilaterally – Biceps, brachioradialis, triceps, patellar, achilles

• Superficial
– Abdominal – Plantar (Negative Babinski) – Cremasteric

Hyperactive. commonly with clonus • Clonus – continued movement after stimulations removed .Reflex Charting • 4+ .

– Ask client to lock fingers and “pull” – Isometric contraction away from muscle group being tested • Try further encouragement of relaxation. • Not brain dependent – often present when unconscious. asleep .DTR Testing • Sometimes need a distraction to help with reflex production.

spinal shock. infectious diseases • 3+ and 4+ . pre-eclampsia. sedation.Abnormal Reflexes • 0 or 1+ . narcosis. ICP.deep coma. • Sustained clonus confirms severe neurological disease .suggest upper motor neuron disease. hypothyroidism. hyperthyroidism.

Biceps Reflex • Support the client’s forearm • Client’s arm flexed at 45-90 degree angle • Hold arm loosely • Strike tendon with a brisk wrist motion on top of your thumb .

Brachioradialis Reflex .

• extension of the forearm. .Triceps Reflex • Relaxed arm required.

• Place hand over quadriceps muscle • Strike patellar tendon just below the patella – blunt end of hammer .Patellar Reflex • Sit on edge of table with leg hanging free.

• Briskly strike Achilles tendon. • Plantar flexion of the foot.Achilles Reflex • Loosely support foot in hand. .

Plantar Reflex • Stroke up the lateral side of the sole & across the ball of the foot to just below the great toe. normal response. • Negative Babinski sign. . • Plantar flexion of the toes.

resistance with pain • Brudzinski’s sign – Chin to chest – involuntary hip flexion and pain .Meningeal Irritation • Nuchal rigidity – Severe pain. knee flexed to 90 degrees. spasms and resistance with gentle neck flexion • Kernig’s sign – Thigh on abdomen.

esp. risk for ischemic brain injuries • Dec rate of nerve conduction • Dec number of neurons (dec. vision/hearing) • Cognitive changes (dec.Gerontological Variations • Inc. short-term memory) . total brain weight) • Dec neurotransmitter amt. & production • Sensory alterations (dec. memory.

. • Decreased ability to identify vibrations at ankle level. • General loss of muscle bulk.Normal Findings after 65 • General knowledge and abilities should be intact. • Irregular shaped pupils. • Decreased muscle tone in face and neck.