Neurological Examination, Med Stud 3

Neurological Examination
Surat Tanprawate, MD, MSc(Lond.), FRCPT Division of Neurology, Chaing Mai University
Thursday, December 15, 2011
Brain function
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
Reex 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 Reex Sensory Coordination Gait and balance
Special test
Consciousness
Higher cortical function : content of consciousness : awareness
: orientation; time, place, person : higher cortical function : Mini-mental state examination
Ascending Reticular Activating System(ARAS) : level of consciousness : wakefulness

: stimuli and response : Glasglow Coma Score(GCS)
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 neurosurgery University of Glascow
1. No eye opening 2. Eye opening in response to pain (Patient ngernail 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
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 patients name and age, where they are and why, the year, month, etc.)
1. 2. 3.
No motor response Extension to pain (abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate posture) Abnormal exion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, exion of wrist, decorticate posture) Flexion/Withdrawal to pain (exion of elbow, supination of forearm, exion of wrist when supra-orbital pressure applied; pulls part of body away when nailbed pinched) Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supraorbital pressure applied.) Obeys commands. (The patient does simple things as asked.)
4.
5.
6.
Consciousness
Impairment of self awareness, person,
environment, time
Clouding of consciousness Confusional state
acute(delirium), chronic(severe dementia)
Consciousness
Level(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 3 Long term memory
Language

Fluency: Comprehension: 1 step, 2 step, 3 step Repetition Naming: Reading Writing
Aphasia
Aphasia refers to an impairment in
linguistic communication produced by brain dysfunction disorders of verbal output such as dysarthria, mutism, and the abnormal language production of patients with thought disorder
It must be distinguished from other
transcortical motor aphasia
Transcortical sensory aphasia
Motor aphasia
Sensory aphasia
Conduction aphasia
A: Wernicke's area B: concept center M: Broca's area a--> A -auditory input to Wernicke's area M --> m -motor output from Broca's area A --> M -tract connecting Wernicke's and Broca's areas A --> B -pathway essential for understanding spoken input B --> M -pathway essential for meaningful verbal output.
Articulatory disorder (aphemia)
Pure word deafness
Lichtheim's diagram of the language system
Praxis
Gnosis
Mini-Mental State Examination (MMSE)
Cranial nerve
Olfactory nerve (CN I)
Test each nose with familiar nonirritate smell
Coffee bean
Optic nerve (CN II)

Visual acuity Visual eld Fundoscopy Swinging ashlight 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 theyre 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 eld
Pupillary response
Direct light reex Consensual light reex
Fundoscopic examination
Cranial nerve III, IV, VI Extraocular movement
Trigeminal nerve (CN V)
Facial sensation Motor: jaw strength

and muscle bulk
Corneal reex
Masseter test
Corneal Reex
Facial nerve (CN VII)

Tear, Ear, Taste, Face
Rinne test
Weber test
Vestibulocochlear nerve (CN VIII)

Vagus nerve (CN X)
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.
Hypoglossus nerve (CN XII)
Motor examination
Muscle bulk Muscle fasciculation/cramp Muscle tone Muscle strength
Reex
Reex
Supercial Reexes
Plantar reex
Stroke lateral side of foot from heel
to the ball, then across to the medial side
Normal response is a positive plantar

reex
Plantar exion of all toes Abnormal response is the Babinski sign

in those 2 yoa
Dorsiexion of the great toe with or

without fanning of the other toes
Sensory function
Sensory function
Primary sensory functions
Always with the persons eyes closed Sites

Vision, hearing, smell, taste, and facial sensation Hands Lower arms Abdomen Feet Lower legs
Sensory function
Primary sensory functions

Supercial touch
Use a cotton wisp Have the person point to the area touched
Supercial pain
Sharp and dull sensations Allow 2 seconds between each stimulus
Temperature and deep pressure

ONLY USED when supercial pain sensation is not intact
Sensory function
Primary Sensory Functions
Vibration
Place stem of tuning fork against bony prominences Begin distally Sites

Up
Sternum Finger wrist elbow - shoulder Toes ankle shin
Position of joints (great toes, one nger on each hand)
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 Rombergs test
Sensory function
Cortical Sensory Functions
Always with the persons 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 supercial 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 Toes Palms Forearms Upper arms and thighs
2-8 mm 3-8 mm 8-12 mm 40 mm 75 mm
Cerebellar function
Coordination and ne 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 nger on the same hand sequentially from index to little nger 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 ne motor skill
Accuracy of movement
Finger-to-nger test with persons 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 Rombergs test
Consequence of Neurologic Exam

Mental status
Consciousness: Level of consciousness, orientation Higher cortical function
Cranial nerves Motor system Reex Sensory Coordination Gait and balance
Special test
Surat Tanprawate, MD, MSc(Lond.), FRCP(T) CertHE(Hist Med) Neurology staff, Division of Neurology, CMU The Northern Neuroscience Center, CMU
Downloadable at www.openneurons.com
Thank You for Your Kind Attention


Neurological Examination, Med Stud 3

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Neurological Examination

Thursday, December 15, 2011

Thursday, December 15, 2011

Thursday, December 15, 2011

Aim of neurological exam

To localized the lesion Central vs Peripheral nervous system

Thursday, December 15, 2011

Thursday, December 15, 2011

Consequence of Neurologic Exam

Consciousness: Level of consciousness, orientation Higher cortical function

Ascending Reticular Activating System(ARAS) : level of consciousness : wakefulness

Thursday, December 15, 2011

Glasglow Coma Score (GCS)

Eye response Verbal response Motor response

Thursday, December 15, 2011

Glasglow Coma Score (GCS)

Thursday, December 15, 2011

Glasglow Coma Score (GCS)

Thursday, December 15, 2011

Glasglow Coma Score (GCS)

Thursday, December 15, 2011

Thursday, December 15, 2011

Clouding of consciousness Confusional state

acute(delirium), chronic(severe dementia)

Thursday, December 15, 2011

Higher Cortical Function

Fluency: Comprehension: 1 step, 2 step, 3 step Repetition Naming: Reading Writing

It must be distinguished from other

Thursday, December 15, 2011

transcortical motor aphasia

Transcortical sensory aphasia

Articulatory disorder (aphemia)

Pure word deafness

Lichtheim's diagram of the language system

Thursday, December 15, 2011

Mini-Mental State Examination (MMSE)

Thursday, December 15, 2011

Thursday, December 15, 2011

Olfactory nerve (CN I)

Test each nose with familiar nonirritate smell

Thursday, December 15, 2011

Optic nerve (CN II)

Thursday, December 15, 2011

Visual acuity: Assessment

Thursday, December 15, 2011

Thursday, December 15, 2011

Thursday, December 15, 2011

Thursday, December 15, 2011

Cranial nerve III, IV, VI Extraocular movement

Thursday, December 15, 2011

Thursday, December 15, 2011

Trigeminal nerve (CN V)

Facial sensation Motor: jaw strength

Thursday, December 15, 2011

Thursday, December 15, 2011

Facial nerve (CN VII)

Thursday, December 15, 2011

Thursday, December 15, 2011

Thursday, December 15, 2011

Vestibulocochlear nerve (CN VIII)

Vagus nerve (CN X)

Hypoglossus nerve (CN XII)

Thursday, December 15, 2011