signs and symptoms of neurological diseases
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Signs and Symptoms of Neurological Diseases. Berrin Aktekin Department of Neurology. Anatomy - CNS. Cerebral Circulation. Originates from carotid and vertebral arteries. Blood Brain Barrier: Prevents diffusion of toxic substances and large molecules. Neurological Conditions. - PowerPoint PPT PresentationTRANSCRIPT
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Signs and Symptoms of Neurological Diseases
Berrin AktekinDepartment of Neurology
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Anatomy - CNS
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Cerebral Circulation
Originates from carotid and vertebral arteries.
Blood Brain Barrier: Prevents diffusion of toxic substances and large molecules.
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Neurological Conditions Cardiovascular event – stroke, aneurysm Encephalitis/ Meningitis Subdural or Epidural Hematoma Post-concussion syndrome Headaches Seizure/ Epilepsy Cerebral palsy Neurodegenerative diseases
Dementia Parkinson
Demyelinating diseases Multiple Sclerosis – MS
Amyotrophic Lateral Sclerosis - ALS Peripheral Neuropathy
Guillain-Barre Syndrome Muscle Disease Cerebellar Disease
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Neurological ExaminationWhat are the components?
Mental Status Language, Speech Cognitive assessment
Meningeal irritationCranial NervesMotor FunctionsReflexes
Deep Tendon reflexes Superficial cutaneous reflexes Pathologic reflexes
Sensory FunctionCerebellar FunctionGait
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Mental Status
Level of alertness, awarenessDegree of interactionOrientationFollowing commandsOlder children: naming objects, simple calculations, extinction, neglect, fund of knowledge
Difference from baseline
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Mental Status AssessmentLevel of Consciousness (LOC)
alert, somnolent, stuporous, comatose.
Orientation: person, place, time
Memory:Immediate, recent remote
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Language, SpeechLanguage
comprehension spontaneous, fluent appropriate content other things you should check: repetition, naming objects,
reading, writingSpeech
prosody volume rate dysarthria
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Cognitive AssessmentThought processCalculationsCurrent eventsResponse to proverbsJudgment & problem solving abilityCommunication abilitiesEmotion- Mood and affect
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MeninigesCoverings of the Brain & Spinal cord
Meninges: 3 layers tissueDura materArachnoid layerPia mater
Spaces: EpiduralSubduralSubarahnoid
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Cerebrospinal fluid:
Contains: no RBC’s, few WBC’s,Glucose 45-75mg/dl,
Protein 15-45 mg/dl.
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Cranial Nerves CN 1: Olfactory…yeah, we don’t check that either CN 2: Optic
Visual acuity Visual fields Fundus
CN 3: Oculomotor Pupil reactivity to light (direct and consensual) and accomadation Extraocular eye movements (superior, medial and inferior recti; inferior
oblique) CN 4: Trochlear
Extraocular eye movements (superior oblique) CN 5: Trigeminal
Muscles of mastication Facial sensation (V1, 2, 3 divisions)
CN 6: Abducens Extraocular eye movements (lateral rectus)
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Cranial Nerves, continued CN 7: Facial
Facial muscles Taste (anterior 2/3)
CN 8: Vestibulocochlear Hearing Vestibular function
CN 9: Glossopharyngeal Taste (posterior 1/3) Uvula
CN 10: Vagus Phonation Palate elevation
CN 11: Spinal accessory Head turn Shoulder shrug
CN 12: Hypoglossal Tongue protrusion
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Motor SystemVoluntary movementI. motor neuron- upper motor neuronExtrapyramidal systemCerebellar systemII. motor neuron- lower motor neuronMuscular system
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Motor Pathways
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Final Common Pathway
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Motor System
StrengthToneMuscle bulk- TrophyReflexesDeep tendon reflexesPathologic reflexesSuperficial cutaneous reflexes
Involuntary movements
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StrenghtCheck agonist/antagonist pairs
Grading system0: no movement1: can see muscle contraction but no movement
2: can move with gravity eliminated3: can move against gravity4: can resist opposition to some extent, but not full (+, - also)
5: full strengthPronator drift: correct position!
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Muscle Tone AssessmentMuscle Tone- ranges from flaccid to tautAtonia - no muscle tone, no resistanceHypotonia-slight muscle tone, little resistance
Hypertonia- too much resistanceSpasticity- stiff, awkward movements Rigidity- tightness, inability to bend
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Muscle bulk-trophyAtrophy
Early II. motor neuron
Late I. motor neuron
HypertrophyPhysiologicPathologicMuscular dystrophy
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Reflexes
Deep tendon reflexesPathologic reflexesSuperficial cutaneous reflexes
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Deep Tendon Reflexes Assessment
Deep tendon reflexes- Have pt. in relaxed position, with joint supported.
DTR – compare L to RShort blow with reflex hammer to the muscle’s insertion tendon (wrist action)
Reinforcement – Have pt. contract muscles not being tested this aids in relaxing muscles to be tested
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DTR GradingScale 0 - 4+
0 = absent,1+ = diminished 2+ = average 3+ = brisk 4+ = hyperactive, clonus
More pathologic descriptors: crossed, spreading
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Pathologic reflexes
HoffmanPalmomentalClonus
Sustained Unsustained
Other grasp, suck, moro, jaw jerk
Plantar response
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Clonus TestingPerform clonus testing if previous reflex testing reveals Hyperactivity
Relax muscle of calfBriskly dorsiflex foot and hold stretch
Clonus = rapid rhythmic contractions
NO CLONUS ( no movement) = normal
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Superficial Cutaneous Reflex Assessment
Abdominal - Umbilicus shifts toward stimulus.
Cremasteric – Testicle on same side of stimulation rises.
Babisnki (Plantar) – Toes flex.
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Involuntary movements:
Tics, Fasciculations (fine tremors)Tremors (resting or intentional)ChoreaBallismusAthetosis
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Lower vs. UpperMotor Neuron Weakness
Upper Motor Neuron
(Brain to corticospinal tract)
Lower Motor Neuron
(Anterior horn cells to peripheral nerves)
Reflexes Hyperactive+/- clonus
Diminished or absent
Atrophy Absent* PresentFasciculatio
nsAbsent Present
Tone Increased (spasticity) Decreased or absentToes Up-going (Babinski’s sign) Down-going
*Disuse atrophy can develop after initial presentation
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Distinguishing Lower Motor Weakness from Muscle Weakness
Neuropathy MyopathyDistribution Distal > proximal Proximal > distal
Fasciculations May be present AbsentReflexes Diminished Often preservedSensory
signs/symptoms
May be present Absent
• Weakness due to neuropathy: lower motor neuron disease.
• Weakness due to myopathy: nerve function intact.
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Sensory SystemFive sense !!!Peripheral Sensory System
SpinothalamicDorsal Column
Cortical-integrative Sensory System
Visceral Sensory System
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Peripheral Sensory System
Spinothalamic system-Cutaneous Pain- Temperature Light touch/pressure
Dorsal Column-Medial Lemniscal System-Proprioception
Vibration Position
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Spinothalamic system
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Dorsal Column-Medial Lemniscal System-
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GraphestesiaStereognosisBarognosisTopognosisTwo point discrimination
Cortical SensoryIntegrative sensation
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Sensory FunctionPerform all sensory testing with
the patient’s eyes closed and test bilaterally.
Components Light touch Pinprick Temperature Vibration Joint position sense Cortical-integrative
Compare sides Proximal/distal Right / left Dermatome Individual peripheral nerves Checking a level
Romberg- correct positioning!
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Cerebellar Functions
Coordination -Corrections of the voluntary motor out-put Rapid alternating
movements Target finding
Tonus Hipotonia
Balance Ataxia
Posture and gait – steady gait with arm swing, balance maintained.
Romberg test – Have pt. stand, feet together, arms side, eyes closed.
Heel to toe gait – tandem walk
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Cerebellar Function AssessmentRapid Alternating Movements (RAM)Hand movements- Tap finger to thumb, rapidly. Tap each finger to thumb rapidly.Pronate and supinate hands rapidly on knees
Finger to nose test – Eyes closed touch finger to nose alternating and increasing speed
Finger to finger test - Have pt. touch his fingertip to your fingertip, alter position.
Heel to shin test – While supine or sitting, have pt run heel of one foot over the shin of opposite leg
Rebound Phenomen
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GaitPosture of body and limbsLength, speed and rhythm of steps
Symmetry and base of gaitSteadinessArm swingTurns Test with normal gait, toe walking, heel walking, tandem walking
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CasualToe HeelTandemWhat are those last 3 testing?
Gait