neurological assessment · neurological s. examination important areas of examination mental...
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Neurological AssessmentINSHIRAH QADRI
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Components of the Central
Nervous System
© Pat Thomas, 2006.
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❑ Cerebral Cortex – “gray matter” center for
highest functions
❑ Cerebrum has two Hemispheres
❑ Four Lobes in each hemisphere: frontal, parietal,
temporal, & occipital
❑ Left Hemisphere – dominant in 95%
Central Nervous System (CNS)
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Central Nervous System© Pat Thomas, 2006.
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Central Nervous System (CNS)
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Frontal Lobe
• Personality
• Behavior
• Emotions
• Intellectual Function
• Precentral gyrus of frontal lobe:
initiates Voluntary movement
(Controls skeletal muscle)
• Broca’s Area: Motor Speech /
Expressive
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Parietal Lobe
❑primary center for sensation.
❑Postcentral Gyrus – Primary
Center for Sensation
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Temporal Lobe
Primary Auditory Center
Taste and Smell
➢ Wernicke’s Area:
➢ Language Comprehension / if damage→Receptive aphasia
➢ No meaning of language, like hearing foreign language
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Occipital Lobe
Primary Visual Receptor
Center
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Cerebellum
• Under the occipital lobe
• Motor coordination, equilibrium,
muscle tone
• Unconscious level that adjusts
voluntary movements
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Brain Stem
Mid brain → Motor neurons &
tracts
Pons → ascending & descending
fibers tracts
Medulla → ascending &
descending fibers tracts connecting
the brain & spinal cord.
Medulla has vital autonomic
nervous system
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Autonomic Nervous System
• works without
conscious thought
(glands, cardiac
muscle, smooth
muscles: digestive
system, respiratory
system & the skin)
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Basal Ganglia
Grey matter deep in the
hemispheres coordinating
motor movements and posture.
E.g.:, the arm swing
Alternating with the legs
during walking
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Forebrain
Cerebrum:
Thalamus: Synapses contact sensory pathways between the spinal cord and the brain stem
Hypothalamus: control center for temperature, heart rate, BP, sleep, ant. & pos. pituitary gland, autonomic nervous system activity & emotional status
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Spinal Cord
carries sensory & motor info.
The main highway that connects the brain to the spinal nerves
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Upper and lower motor neurons
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Peripheral Nervous System
• Reflex Arc, Cranial
nerves, Spinal
nerves.
Cranial Nerves – 12 pairs31 pairs
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The Nerve
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Sensory stimulus, posterior
root, spinal cord, synapse
with a motor neuron in the
anterior horn, anterior root,
muscle.
Reflex arc:
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Types of Reflexes
Deep Tendon – knee jerk,
(patellar)
Superficial – corneal reflex, abd.
Reflex
Visceral – organic, pupil response
to light & accommodation
Pathologic – abnormal / Babinski.
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Cranial Nerves
• enter and exit the brain
• The 12 pairs of CN supply the
head and neck except the vagus
nerve which travels to the heart
,resp. muscle ,stomach and
gallbladder.
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Subjective Data
• Headache
• Incoordination
• numbness or tingling
• Difficulty swallowing
• Difficulty speaking
• past history
• Head injury
• Dizziness
• Seizures
• Tremors
• weakness
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Neurological S. Examination
IMPORTANT AREAS OF EXAMINATION
Mental status— Behavior and Mental Status. (level of consciousness & orientation).
Cranial nerves — I through XII
Motor system — coordination, gait, & stance
Sensory system — pain and temperature, position & vibration, light touch, discrimination.
Deep tendon — abdominal, and plantar reflexes
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Test Cranial Nerves
I: Olfactory :S / test sense of smell
II: Optic: S / Visual acuity & fields and
ophthalmoscope
III, IV,VI: oculomotor, trochlear,
abdocent):S /M Pupils size, reflex,
accommodation & asses extra ocular
movement.
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V: trigeminal
M /clench teeth (muscles of
mastication)
S / cotton wisp to face; light
touch& corneal reflex
(blink).
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VII: facial: M / facial
expression during movements;
smile, close eyes then open,
frown, lift eyebrows, show
teeth. puff cheeks
S / taste (sugar, salt, lemon).
VIII: Acoustic: S / hearing
acuity; whisper, Weber, Rinne
and Romberg’s tests
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IX & X: glossopharyngeal & vagus
M / uvula & soft palate rise, positive
gag reflex,
Assess quality of nasal voice. Is it
hoarse? .vocal cord paralysis.
Palate paralysis nasal voice
Assess swallowing
S /IX CN taste on post 1/3 tongue
(biter)
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XI (spinal accessory N) :M /
shoulder shrug, neck muscle strength
ROM .
XII (hypoglossal N) – M / tongue
midline w/ forward thrust, say “light,
tight, dynamite”
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Inspect & Palpate the motor
system
• Muscle size• Appropriate to age, symmetric or < 1cm
difference
• Strength • Equal bilaterally.
Tone = normal degree of tension in relaxed muscles
• Mild resistance to passive stretch
• Involuntary movement
• Absent
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Cerebellar Function
Balance Test:
Gait: observe a person walk 10-20 ft. & return to
starting point smooth, rhythmic ,effortless, well
coordinated with hand, step length 15 inch from
heel & smooth turns.
Walk straight & stay balanced ,while walking
straight line in a heel to toe (Tandem walking).
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Cerebellar
Function
• Romberg test; ask the person to stand up with feet togother and arms at sides, close eyes.
Noramal➔ maintain posture & balance with slight swaying.
• shallow knee bend or to hop in place;
• Balanced
• Rising up (if the client old age or weak )
• Unable to perform shallow knee bend or hop
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Coordination
Rapid alternating movement (RAM);
• quick rhythmic pace & smoothnes .
Thumb index test
• quick rhythmic pace & smoothnes .
Counting the fingers; quick & accurately.
Finger to finger; smooth & accurate movement.
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• Finger to nose ; smooth &
accurate movement
• Heel to shin: moves heel in a
straight line down the shin.
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Sensory System Assessment
• Ensure the client is alert, cooperative, comfortable & has an adequate attention span.
• Compare sensations on symmetrical body parts.(bilaterally)
• Proceed from the point of decreased sensation toward the sensitive area
• Draw results on a diagram
• If discover abnormity perform all sensation tests
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Sensory System Assessment
➢Ask the person to close eyes
➢Routine screen includes light touch, superficial pain, vibration & stereognosistest.
➢Avoid leading questions- use unbiased directions
➢May need to repeat the sensory tests or break it into parts when the client tired.
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Sensory System Assessment
Spinothalamic Tract:
Pain – perceive a pinprick
with at least 2 sec. elapse
between each stimulus
Dscriminate sharp & dull
points; bilaterally, feel
symmetric .
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Sensory System Assessment
Spinothalamic Tract:
Temperature –able to
discriminate heat & cold stimuli
bilaterally.
Light Touch – apply a wisp of
cotton to skin, brush over the skin
in random order and irregular
intervals
• able to feel, symmetric.
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Posterior column tract
Vibration – tuning fork
( 128Hz) over bony
prominences
• able to feel vibration
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Posterior column tract
• Proprioception (Position )
;Kinesthesia: ability to perceive
passive movement of extremities.
Move a finger or toe up & down
Normal: detect movement
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Posterior column tract
Stereognosis – recognition
of familiar objects by feeling
size & weight With closed
eyes.
Graphesthesia – read a
number by traced on skin
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Posterior column tract
Two points discrimination;
able to distinguish the separate
of two pin points on the skin.
Normal: varied with the tested
region
The most sensitive is the finger
pads: (normally < 5 mm on the
fingerpads).
The least sensitive – the upper
arms, thighs, and back
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Posterior column tract
Extinction; able to feel
stimulus at both sides of
the body.
Point location; able to
localize the sensation
touch.
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Reflexes (response graded 0 – 4+)
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Deep tendon reflexes
Reinforcement.
❑Test reflexes using a percussion hammer,
comparing one side of the body with the other to
evaluate the symmetry of response.
❑The client should be clench teeth, make fist or
squeeze one thigh with the opposite hand for
arms
❑The client should be interlock fingers and pull
one hand against the other for legs.
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Reflexes
• Biceps Reflex – (C5 to C6) striking on
bicep → Forearm flexion
• Triceps Reflex–( C7-C8) extension of
forearm+striking on the triceps tendon
• Brachioradialis Reflex C5-C6 – flexion
& supination of forearm while striking
2 inch above the wrist.
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Reflexes
Quadriceps Reflex (knee Jerk )
L2-L4 → leg extension
Achilles Reflex (ankle Jerk)
L5-S2 striking on the Achilles
→ plantar flexes against your
hand
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Superficial reflexes
Abdominal reflexes (upper T8-
T10,lower T10 -L2) → Ipsilateral contraction of the abdominal muscle with deviation the umbilicus toward the stroking,
Cremasteric reflex (L1-L2); strok the
inner aspect of the thigh → elevation of the ipsilateral testicle
Planter reflex (L4-S2);
→ plantar flexion of the, inversion & flexion of the forefoot