INT - Neurological examination Flashcards
NEUROLOGICAL EXAMINATION:
- Ask
- Watch
- Touch
- Pain
WATCH:
• Inspection (without move)
◦body posture
◦head position
◦eye position, -movement
◦consciousness
WATCH:
• Inspection (on move)
◦walk
◦turn
◦sit-stand
TOUCH:
- palpation (symmetry, muscle atrophy, crepitation, fracture)
- postural reactions, spinal reflexes
- cranial nerves
- sensitivity of the skin and mucous membranes
- manipulation
PAIN:
• Pain sensation
◦superfitial
◦deep pain
DISEASE PROCESSES:
DAMNITV
DISEASE PROCESSES:
What is DAMNITV
D. Degenerative eg lipofuscinosis - difficult to diagnose
A. Anomalous eg hydrocephalus
M. Metabolic eg hepatic encephalopathy
N. Neoplastic eg tumor
I. Inflammatory eg steroid-responsive meningitis-arteritis
I. Infectious eg bacterial, viral
I. Idiopathic eg idiopathic vestibular syndrome
T. Toxic eg ethylene glycol toxicity
V. Vascular eg ischemia, bleeding
PHYSICAL EXAMINATION - HEAD/SKULL
- Shape (symmetrical - asymmetrical changes)
- Mobility
- Ears (drooping or pointing
- Signs of pain by palpation
MENTAL STATE - INAPPROPRIATE MENTAL FUNCTION
• Reduced:
◦Depressed, obtunded, dull, blunt, indolent: lowering or decrease of functional activity
◦Somnolentia: drowsiness
◦Delirium: mental disturbance (hallucinations, illusions, restlesness, incoherence)
◦Dementia: organic loss of intellectual function
MENTAL STATE - INAPPROPRIATE MENTAL FUNCTION
• Increased:
◦Exitatio: excitement
◦Aggressive: attacking
◦Furor: rage
OTHER FORMS OF CONVULSIONS NOT NECESSARILY CONNECTED TO CNS
- Tetanus: sustained tonic contraction of muscles without twitching
- Tetany: violent muscle twitching over the whole body
- Tremor: regular, rhythmic trembling (oscillation) of muscles
- Tic: repetitive contractions of one muscle
- Myoclonus: rhythmic contraction of one muscle group
- Fibrillation: uncoordinated twitching of individual muscle fibres
EXAMINATION OF PROPRIOCEPTION: POSTURAL REACTIONS
• Wheelbarrowing test
• Hopping tests
◦On one leg
◦Hemihopping
• Knuckling-over test
• Placing reactions
◦Tactile
◦Visual
• Extensor postural thrust reactionATAXIA
• Classification by
• Classification by signs: • Classification by anatomical origin: ◦Cortical: ◦Cerebellar: ◦Vestibular: ◦Spinal (proprioceptive):
ATAXIA
• Classification by signs:
◦Static: signs in standing position (as well)
◦Locomotive: signs during movement only
◦Intentional: tremor of the head when fine adjustment is demanded
ATAXIA
• Classification by anatomical origin:
◦Cortical:
‣ circling, lateral head turn, behavior changes, altered mental state
◦Cerebellar:
‣ wide-based stance, dysmetria-hypermetria, (nystagmus)
◦Vestibular:
‣ ipsilateral head tilt leans to the affected side, nystagmus
◦Spinal (proprioceptive):
‣ paresis/paralysis (muscle weakness) frequent
‣ Hindlimbs are always affected
PARESIS, PARALYSIS/PLEGIA:
• Diagnostic methods
◦Inspection ◦Palpation ◦Evaluation of muscle tone ◦Atony ◦Hypotony (reduced muscular tone ◦Hypertony (increased muscular tone)
CLASSIFICATION OF PARALYSIS:
• by
- by severity
- by affected limbs
- by muscle tone
- by origin, related to neuron nucleus
CLASSIFICATION OF PARALYSIS:
• by severity
◦paresis = partial loss of strength ◦paralysis/plegia = complete loss of strength
CLASSIFICATION OF PARALYSIS:
• by affected limbs
◦monoparalysis (-plegia, -paresis): one limb
◦tetraparalysis (-plegia, -paresis): all limbs
◦paraparalysis (-plegia, -paresis): rear/hind limbs
◦hemiparalysis (-plegia, -paresis): ipsilateral limbs
CLASSIFICATION OF PARALYSIS:
• by muscle tone
◦spastic, rigid
◦atonic, flaccid
CLASSIFICATION OF PARALYSIS:
• by origin, related to neuron nucleus
◦UMN (upper motor neuron): above the nucleus
◦LMN (lower motor neuron): in or below the nucleus
EXAMINATION OF CRANIAL NERVES: #1
N. Olfactorius I - Smelling
• Patho:
Hyposomia (partial loss) & Anosomia (complete loss of smell)
• Tests: Use strong stimuli objects/materials
• EXCLUDE VISION (avoid to stimulate Opticus) & DON’T IRRITATE NASAL MUCOSA (which stimulates Trigeminus)
EXAMINATION OF CRANIAL NERVES: #2
N. Opticus II - Vision
• Patho: Amaurosis (blindness)
• Tests: Falling cotton test, pupillary light reaction direct & indirect (+Occulomotorius), threat/menace
reflex (+Facial)
• AVOID AIR CURRENT (which stimulates Trigeminus) & TOUCHING SENSORY HAIR (which
stimulates Trigeminus)
EXAMINATION OF CRANIAL NERVES: #3
N. Occulomotorius III - Pupils constriction
• Patho: Anisocoria (uneven size of pupils), Mydriasis (dilatation), Miosis (constriction)
• Horner’s syndrome: Loss of sympathetic innervation
◦Ipsilateral miosis (on affected side),
◦Ipsilateral ptosis (upper eyelid slagging down slightly
◦Enophtalmus (sunken eye)
◦Prolapse of 3rd eyelid
Examination of position & movement of eyeballs:
N. Occulomotorius, N. Trochlearis, N. Abducens
• Patho:
• 1) Spontaneous Nystagmus (horizontal, vertical, rotatory).
◦Can be physiological/provoked when moving the head manually: Involuntary eye movements
(+Vestibulochoclearis)
• 2) Strabism (abnormal position of eyeballs, not parallel with each other)
◦Strabismus divergens - Ventrolateralis - N. Occulomotorius paralysis
◦Strabismus medioventralis - N. trochlearis paralysis
◦Strabismus convergens - Medialis - N. Abduscens paralysis
EXAMINATION OF CRANIAL NERVES: #5
N. Trigeminus V - Sensory & motor function
- Sensory = Feeling of face, Palpebral reflex (+Facial), Corneal reflex (+Facial)
- Motor = Prehension of food, drinking & chewing via innervation of m. Temporalis and m. Masseter
• Patho: Paralysis (sagging of lower jaw), Tic (repeated contractions of chewing muscles eg
distemper), Trismus (Tonic spasm of chewing muscles eg tetanus)
- Tests: Corneal reflex, palpebral reflex (lateral and medial canthus)
- TRY TO STAY OUTSIDE OF VISION FIELD to not induce threat reflex.
EXAMINATION OF CRANIAL NERVES: #7
N. facialis VII -
Mainly motor nerve, with Gustatory sensory function of 2/3 rostral tongue.
Responsible for:
• Threat reflex (+Opticus)
• Palpebral reflex (+Trigeminus)
• Corneal reflex (+Trigeminus).
Patho: Paralysis (uni or bilateral)
Diagnostic: • Nasal plane will be drawn toward the healthy side in unilateral paralysis • Sagging of upper eyelid: Ptosis • Sagging of lip • Sagging of ears (central damage)
Tests: Try to gently touch the nasal plate, the ears’hair, and observe symmetry
EXAMINATION OF CRANIAL NERVES: #8
N. Vestibulocochlearis VII
- Hearing & balance
1) Pars cochlearis - Hearing
Patho: Anacusis (deafness) which can be congenital or acquired
Tests : Calling, clapping outside of vision field
• AVOID TO STIMULATE N.OPTICUS
2) Pars staticus - Vestibular division
Patho: Vestibular syndrome
Diagnostic: Ipsilateral head tilt, leaning and falling, nystagmus (mostly horizontal) toward side of lesion
EXAMINATION OF CRANIAL NERVES: #9
N. Glossopharyngeus IX (sensory) & N. Vagus X (motor) - Innervation of larynx & pharynx & 1/3
caudal tongue
Patho: Swallowing problem causing Dysphagia,
Tests: Swallowing reflex is tested with water or feed, touching the base of the tongue or external
compression of throat
EXAMINATION OF CRANIAL NERVES: #11
N. Accessorius XI - Motor nerve of trapesius, sternocephalicus, brachiocephalicus
Patho: Paralysis & sagging of head, atrophy of muscles on neck & shoulder
EXAMINATION OF CRANIAL NERVES: #12
N. Hypoglossus XII
- Tongue protruding & retracting
Patho: Paralysis of the tongue, bilateral (diagnosed by prolapse of the tongue) or unilateral (tongue is
deviated)
Tests: Check tongue protrusion and withdrawal after swallowing & check the strength of retraction after
grasping it.
EXAMINATION OF SPINAL REFLEXES
Evaluation of a reflex
0 = areflexia 1 = hyporeflexia 2 = normoreflexia 3 = hyperreflexia 4 = hyperreflexia with clonus: series of rapid contractions of a muscle in response to a single stimulus
EXAMINATION OF SPINAL REFLEXES
Abnormal reflexes
• reflex irradiation:
◦a reflex elicited in a larger area / muscle group than expected
• contralateral (crossed) reflex:
◦a reflex elicited in response to a stimulus applied to the other side of the body
EXAMINATION OF PAIN PERCEPTION:
SUPERFICIAL PAIN
- Skin (mucous membrane)
- Pain provoking percussion
- Normal response
- Pathway: receptor - spinal ganglion – thalamus - cortex
- Evaluation:
EXAMINATION OF PAIN PERCEPTION:
SUPERFICIAL PAIN
• Skin (mucous membrane)
◦Pinching with hemostat
◦Pricking with needle
EXAMINATION OF PAIN PERCEPTION:
SUPERFICIAL PAIN
• Normal response
◦skin twitch, leg withdrawal
‣ = spinal reflex (panniculus and flexor)
◦Behavioral: crying, biting, turning to direction of pain
‣ = conscious pain perception
EXAMINATION OF PAIN PERCEPTION:
SUPERFICIAL PAIN
• Evaluation:
◦normaesthesia
◦hyperaesthesia
◦anaesthesia
◦paraesthesia
