neurological examination, med stud 3

Neurological Examination

Surat Tanprawate, MD, MSc(Lond.), FRCPTDivision of Neurology, Chaing Mai University

Thursday, December 15, 2011

Brain function


Neurological skill• Chief complaint

• History taking

• Neurological examination

• screening neurological examination

• focused neurological examination

• Consequence of the exam

• Skill and method


Aim of neurological exam

• To localized the lesion

• Central vs Peripheral nervous system

• symmetrical vs asymmetrical

• If central: cerebrum, midbrain, spinal cord

• If peripheral, is it: nerve, muscle, NMJ


Equipment• Penlight

• Tongue blade

• Tuning fork

• Familiar objects(coin, key, paper clip)

• Cotton wisp

• Reflex hammer

• Aromatic substances

• Test tubes of hot and cold water


Consequence of Neurologic Exam

• Mental status

• Consciousness: Level of consciousness, orientation

• Higher cortical function

• Cranial nerves

• Motor system

• Reflex

• Sensory

• Coordination

• Gait and balance Special testThursday, December 15, 2011

Consciousness

Ascending Reticular Activating System(ARAS): level of consciousness: wakefulness: stimuli and response: Glasglow Coma Score(GCS)

Higher cortical function: content of consciousness: awareness: orientation; time, place, person: higher cortical function: Mini-mental state examination


Level of consciousness

• Wakefulness

• Drowsiness

• Semi-coma

• Coma


Glasglow Coma Score (GCS)

• Eye response

• Verbal response

• Motor response First published in 1974 by Graham Teasdale and Bryan J. Jennett,

Professor of neurosurgeryUniversity of Glascow



1. No eye opening

2. Eye opening in response to pain (Patient fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)

3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.)

4. Eyes opening spontaneously

E



1. No verbal response

2. Incomprehensible sounds. (Moaning but no words.)

3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)

4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)

5. Oriented (Patient responds coherently and appropriately to questions such as the patientʼs name and age, where they are and why, the year, month, etc.)

V



1. No motor response

2. Extension to pain (abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate posture)

3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate posture)

4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)

5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)

6. Obeys commands. (The patient does simple things as asked.)

M


Consciousness

• Impairment of self awareness, person, environment, time

• Clouding of consciousness

• Confusional state

• acute(delirium), chronic(severe dementia)


ConsciousnessLevel(arousal) and content(awareness) of

consciousness

Arousal and awareness, the two components of consciousness in coma, vegetative state, minimally conscious state, and locked-in syndrome.


Higher Cortical Function

• Memory

• Language

• Calculation

• Higher motor function(Praxis)

• Higher sensory function(Gnosis)


Memory

• Short term memory

• ถามคําให้ทวน 3 คํา “ต้นไม้ รถยนต์ มือ”

• Long term memory

• ชื่อประเทศ ชื่อพ่อแม่


Language• Fluency: ความคล่องของการพูด

• Comprehension: 1 step, 2 step, 3 step

• Repetition “ยายพาหลาน ไปซื้อขนมที่ตลาด”

• Naming: ปากกา นาฬิกา แก้วน้ํา

• Reading

• Writing


Aphasia• Aphasia refers to an impairment in

linguistic communication produced by brain dysfunction

• It must be distinguished from other disorders of verbal output such as dysarthria, mutism, and the abnormal language production of patients with thought disorder


A: Wernicke's areaB: concept centerM: Broca's area

a--> A-auditory input to Wernicke's areaM --> m-motor output from Broca's areaA --> M-tract connecting Wernicke's and Broca's areasA --> B-pathway essential for understanding spoken inputB --> M-pathway essential for meaningful verbal output.

Lichtheim's diagram of the language system

Conduction aphasia

Transcorticalsensory aphasia

transcortical motor aphasia

Pureword deafness

Articulatory disorder (aphemia)

Sensory aphasia

Motor aphasia


Praxis

Gnosis


Mini-Mental State

Examination (MMSE)


Cranial nerve


Olfactory nerve (CN I)

• Test each nose with familiar non-irritate smell

• Coffee bean


Optic nerve (CN II)

• Visual acuity

• Visual field

• Fundoscopy

• Swinging flashlight test


Visual acuity

• Using hand held card (14 inches) or snellen wall chart, assess each eye separately

• Direct patient to read aloud line with smallest lettering that theyʼre able to see


Visual acuity: Assessment

• 20/20 = patient can read at 20` with same accuracy as person with normal vision.

• 20/400 = patient can read at 20` what normal person can read from 400` (i.e. very poor acuity).


Visual field


Pupillary response

Direct light reflex

Consensual light reflex


Fundoscopic examination


Cranial nerve III, IV, VIExtraocular movement


Trigeminal nerve (CN V)

• Facial sensation

• Motor: jaw strength and muscle bulk

• Corneal reflex


Masseter test


Corneal Reflex


Facial nerve (CN VII)

“Tear, Ear, Taste, Face”


Vestibulocochlear nerve (CN VIII)

Rinne test

Weber test


A normal soft palate is illustrated on the left. On the right, a right palatal palsy from a lower motor neuron X nerve lesion has resulted in deviation of the uvula to the left.

Vagus nerve (CN X)

Hypoglossus nerve (CN XII)


Motor examination

• Muscle bulk

• Muscle fasciculation/cramp

• Muscle tone

• Muscle strength


Reflex


ReflexSuperficial Reflexes

• Plantar reflex• Stroke lateral side of foot from heel to the ball, then across to the medial side• Normal response is a positive plantar

reflex• Plantar flexion of all toes

• Abnormal response is the Babinski sign in those 2 yoa• Dorsiflexion of the great toe with or

without fanning of the other toes


Sensory function


Sensory function• Primary sensory functions

• Always with the personʼs eyes closed

• Sites

• Vision, hearing, smell, taste, and facial sensation• Hands• Lower arms• Abdomen• Feet• Lower legs


Sensory function• Primary sensory functions

• Superficial touch

• Use a cotton wisp

• Have the person point to the area touched

• Superficial pain

• Sharp and dull sensations

• Allow 2 seconds between each stimulus

• Temperature and deep pressure

• ONLY USED when superficial pain sensation is not intact


Sensory function• Primary Sensory Functions

• Vibration• Place stem of tuning fork against bony prominences

• Begin distally

• Sites

• Sternum

• Finger – wrist – elbow - shoulder

• Toes – ankle – shin

• Position of joints (great toes, one finger on each hand)• Up

• Down


Proprioception• Proprioception

• The sensation of position and muscular activity originating from within the body which provides awareness of posture, movement, and changes in equilibrium

• Test

• Joint position test

• Rombergʼs test


Sensory function• Cortical Sensory Functions

• Always with the personʼs eyes closed

• Stereognosis

• Ability to identify a familiar object by touch and manipulation

• Tactile agnosia: inability to recognize objects

• Graphesthesia

• With a blunt pen, draw a letter or number on the palm

• Should be readily recognized


Sensory function• Cortical Sensory Functions

• Point location

• Touch an area of the body and ask the person to point to where you have touched

• This is being tested the same time as superficial touch

• Extinction phenomenon

• Simultaneously touch one or both sides of the body

• Ask the person to point to where you have touched


Sensory function• Cortical sensory functions

• Two-point discrimination

• Use two pointed objects, alternate touching skin with one or two points

• Find the distance at which the person can no longer discriminate 2 point

• Finger tip 2-8 mm• Toes 3-8 mm• Palms 8-12 mm• Forearms 40 mm• Upper arms and thighs 75 mm


Cerebellar function• Coordination and fine motor skill

• Rapid rhythmic alternating movement

• Have seated person alternately pronate and supinate hands, patting knees, and gradually increasing speed OR

• Have person touch thumb to each finger on the same hand sequentially from index to little finger and back, gradually increasing speed

• person should be able to do these movements smoothly, maintaining rhythm, with increasing speed

• Observe for slow, stiff, non-rhythmic, or jerky movements


Cerebellar function

• Coordination and fine motor skill• Accuracy of movement

• Finger-to-finger test with personʼs eyes open

• Movements should be rapid, smooth, and accurate

• Consistent past pointing may indicate cerebellar impairment

• Heel-to-shin with person supine

• Should move heel from knee up and down the shin in a straight line, without irregular deviations to the side


Finger-to-nose test. A. Normal: Smooth trajectory throughout movement. B. Cerebellar hemisphere dysfunction: Tremor increases in amplitude as finger approaches target. C. Parkinsonian: Tremor may be present at initiation of movement, but smoothes out as finger approaches target. D. Essential tremor: Low-amplitude fast tremor throughout trajectory, may worsen as finger approaches target.


Cerebellar function

• Stance and gait

• Gait

• Tamdem walk

• Rombergʼs test


Consequence of Neurologic Exam

• Mental status

• Consciousness: Level of consciousness, orientation

• Higher cortical function

• Cranial nerves

• Motor system

• Reflex

• Sensory

• Coordination

• Gait and balance Special testThursday, December 15, 2011

Thank You for Your Kind Attention

Surat Tanprawate, MD, MSc(Lond.), FRCP(T)CertHE(Hist Med)Neurology staff,

Division of Neurology, CMUThe Northern Neuroscience Center, CMU

Downloadable at www.openneurons.com


http://www.openneurons.com

http://www.openneurons.com

neurological examination, med stud 3

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