Nervous System Past Paper PDF 2023

Nervous System PA 634 2023 Clint C. Blankenship, PharmD, PA-C, RPh, DFAAPA Division of Physician Assistant Studies Medical University of South Carolina 1 Brain • Major areas of gray matter: neural cell bodies – Cerebrum – Cerebellum: movement, coordination, balance, posture – Basal ganglia: vol...

Nervous System PA 634 2023 Clint C. Blankenship, PharmD, PA-C, RPh, DFAAPA Division of Physician Assistant Studies Medical University of South Carolina 1 Brain • Major areas of gray matter: neural cell bodies – Cerebrum – Cerebellum: movement, coordination, balance, posture – Basal ganglia: voluntary movement, cognition, emotion, learning (habitual and procedural) – Thalamus: relay station, regulator (consciousness, sleep, alertness) – Hypothalamus: homeostasis, temperature, heart rate, blood pressure, endocrine control, emotional behavior, sex drive • White matter: myelinated axons 2 FYI: Brainstem 3 Spinal Cord 4 Spinal Cord and Spinal Tracts • Spinal and peripheral nerves relay impulses to and from the spinal cord • 31 pairs of spinal nerves – – – – – • 8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal Each nerve has: – Ventral (anterior) root: motor fibers – Dorsal (posterior) root: sensory fibers 5 Motor Pathways 6 Upper Motor Pathways • Pyramidal tracts: – Originate in motor cortex and most fibers decussate in lower medulla (structure resembles a pyramid) – Corticospinal tracts: • Mediate voluntary movement and integrate complicated/delicate movements • Stimulate some muscles while inhibiting others – Corticobulbar tracts: • Motor nuclei of CNs – Eye, tongue, chewing 7 8 Upper Motor Pathways • Basal ganglia system: – Complex system of pathways between multiple areas of the brain and spinal cord – Helps to maintain muscle tone – Helps in control coordination of body movements (especially gross movements such as gait) • Cerebellar system: – Coordinates motor activity, maintains equilibrium, and helps control posture 9 Motor Pathway Damage • Impairment will be seen below the level of damage (e.g., lesion, ischemia/infarction) • Damage above decussation leads to motor impairment on contralateral side • Damage below decussation leads to motor impairment on ipsilateral side 10 Lower Motor Pathway • Neurons that carry signal from spinal cord to muscle 11 Motor Pathway Damage • UMN lesion: – Increased muscle tone – Exaggerated DTR • LMN lesion: – Ipsilateral weakness/paralysis – Decreased muscle tone – Decreased or absent DTR 12 Motor Pathway Damage • Basal ganglia and cerebellar damage usually doesn’t result in paralysis but can have a major impact on function • Basal ganglia: – – – – • Usually increased muscle tone Posture and gait Bradykinesia (slow movements) Involuntary movements Cerebellar: – – – – Decreased muscle tone Gait Coordination Balance (equilibrium) 13 Peripheral Nervous System • Nerves and ganglia outside the CNS: – Cranial nerves (except I and II) – Peripheral nerves • Relay between CNS and rest of body • Divisions: – Somatic nervous system: muscle movements, response to sensory input – Autonomic nervous system: input to organs and autonomic reflex responses • Sympathetic nervous system (SNS) • Parasympathetic nervous system (PNS) 14 Sensory Pathways 15 Sensory Impulse Actions • • • • Part of reflex activity Conscious sensation Body position (proprioception) Regulate autonomic functions 16 Sensory Pathways • Input from point of sensation to dorsal root ganglia • Impulse then travels up (ascends) spinal cord to sensory cortex of brain via one of two tracts 17 Sensory Pathways • Spinothalamic tract: small-fiber tract – From skin to dorsal horn to thalamus – Pain, temperature, crude touch • Posterior column: large-fiber tract – From skin and joints to medulla to thalamus – Vibration, proprioception\kinesthesia, pressure, fine touch • Example of diabetic neuropathy: – Burning/shooting pain: small-fiber neuropathy – Numbness and tingling or paresthesia: large-fiber neuropathy 18 Sensory Pathways • Thalamic level: – General sensation is perceived but lacks fine distinctions • Sensory cortex: – Neurons carry impulse from thalamus to cortex for full perception – Stimuli are localized and higher-order discriminations made 19 Sensory Pathways • Lesions at different levels cause different deficits – Example: • Cortical lesion may cause loss of perception of size, shape, texture of an object but they will still perceive pain, touch, and position • Need to put pattern of sensory loss together with motor findings to help locate lesion 20 21 Dermatomes 22 23 Muscle Stretch Reflexes 24 25 Muscle Stretch Reflexes • Relayed over structures of both the CNS and PNS • An involuntary stereotypical response that may involve as few as two neurons, one afferent (sensory) and one efferent (motor), across a single synapses • Other reflexes are polysynaptic, involving interneurons interposed between sensory and motor neurons 26 Muscle Stretch Reflexes • To elicit a muscle stretch reflex, briskly tap the tendon of a partially stretched muscle – Activates sensory fibers in the partially stretched muscle • Triggers a sensory impulse that travels to the spinal cord via a peripheral nerve – Sensory fiber synapses directly with the anterior horn cell innervating the same muscle – When the impulse crosses the neuromuscular junction, the muscle suddenly contracts, completing the reflex arc • For the reflex to occur, all components of the reflex arc must be intact: – – – – – Sensory nerve fibers Spinal cord synapse Motor nerve fibers Neuromuscular junction Muscle fibers 27 Muscle Stretch Reflexes • Each muscle stretch reflex involves specific spinal segments, together with their sensory and motor fibers • An abnormal reflex helps you locate a pathologic lesion • Learn the segmental levels of the muscle stretch reflexes • Muscle stretch reflexes and corresponding spinal segments: – – – – Cervical 5-6: biceps and brachioradialis Cervical 6-7: triceps Lumbar 2–4: knee Sacral 1: ankle 28 Cutaneous Reflexes • Reflexes may be initiated by stimulating skin as well as muscle • Stroking the skin of the abdomen, for example, produces a localized muscular twitch • Superficial (cutaneous) reflexes and corresponding spinal segments: – – – – – Thoracic 8-10: upper abdomen Thoracic 10-12: lower abdomen Lumbar 1-2: cremasteric reflex Lumbar 5, sacral 1: plantar reflex Sacral 2-4: anal reflex 29 Examination Techniques 30 General Neurologic Examination • Categories: – Mental status, speech, and language • More specifics in FCM during psychiatry block – – – – – Cranial nerves Motor system Sensory system Muscle stretch reflexes Coordination 31 Mental Status • • • • • • • • • Level of consciousness (arousal) Attention and concentration Memory (immediate, recent, and remote) Language Visual spatial perception Executive functioning Mood and thought content Praxis (perform voluntary skilled movements) Calculations 32 Level of Consciousness Level Technique Patient Response Alertness Speak to the patient in a normal tone of voice. • Opens the eyes, looks at you, and responds fully and appropriately to stimuli (arousal intact) Lethargy Speak to the patient in a loud voice. • Appears drowsy but opens the eyes and looks at you, responds to questions, and then falls asleep Obtundation Shake the patient gently as if awakening a sleeper. Stupor Coma • Opens the eyes and looks at you but responds slowly and is somewhat confused • Alertness and interest in the environment are decreased • Arouses from sleep only after painful stimuli Apply a painful stimulus. For • Verbal responses are slow or even absent example, pinch a tendon, rub the • Lapses into an unresponsive state when the stimulus sternum, or roll a pencil across a ceases nail bed. • Minimal awareness of self or the environment Apply repeated painful stimuli. • Remains unarousable with eyes closed • No evident response to inner need or external stimuli 33 “A&O” • Alert and oriented x 3 (or 4) • Alert: awake and able to follow commands • Oriented – – – – Person Place Time Situation 34 Cranial Nerves 35 I: Olfactory • Check each nasal passage is patent • Have patient close both eyes • Occlude one nostril and have patient identify odor – Use something that will not cause irritation (e.g., coffee, soap) • Repeat on other side 36 II: Optic • Visual acuity • Visual fields by confrontation – Test each eye separately and both together • Funduscopic examination 37 II and III: Optic and Oculomotor • Pupils: – Inspect: size and shape – Reaction to light – Accommodation 38 III, IV, and VI: Oculomotor, Trochlear, and Abducens • Inspect for ptosis • Extraocular movements – Six cardinal directions – Note any deviations or nystagmus LR6SO4R3 • Test for convergence 39 V: Trigeminal • Motor: – Test strength and symmetry of major mastication muscles (temporal, masseter, lateral pterygoid) – Palpate temporal and masseter while patient clenches teeth – Have patient open jaw and move side to side 40 V: Trigeminal • Sensory: – Test pain sensation on forehead, cheeks, and chin by using a sharp object – Most often use a splinter from a broken/twisted cotton swab – Have patient close eyes during exam and state whether “sharp or dull” – If sensation deficit, check temperature sensation – Test light touch by using wisp of cotton • Nerve divisions: – Ophthalmic – Maxillary – Mandibular 41 V: Trigeminal and VII: Facial • Corneal reflex: – Test sensation of cornea (CN V) and motor reaction (CN VII) – Must remove contact lenses – Have patient look up and away – Approach out of line of vision – Avoid eyelashes and touch cornea with wisp of cotton – Normal reaction is blinking 42 VII: Facial • Inspect while talking with patient for symmetry, tics, abnormal movements and then test by performing the following maneuvers • • • • • • Raise both eyebrows Close both eyes tightly against resistance Smile/frown Show both upper and lower teeth Purse lips Puff out both cheeks 43 VIII: Vestibulocochlear • Assess hearing – Whispered voice or finger rub – Each ear separately – If unilateral loss, perform Weber and Rinne tests 44 IX and X: Glossopharyngeal and Vagus • Assess patients voice while discussing the history – Hoarseness can be from vocal cord paralysis – Nasal voice can be from paralysis of palate • Ask patient to say “ah” and watch movement of soft palate and pharynx – Normal: palate rises symmetrically with uvula midline and sides of posterior pharynx move medially • Assess swallowing • Test gag reflex: rarely done unless deficit is found from other tests 45 XI: Spinal Accessory • Inspect trapezius and SCM muscles for atrophy, fasciculations, and symmetry • Have patient shrug shoulders against resistance (trapezius) • Test SCM by having patient turn their head to each side against resistance 46 XII: Hypoglossal • Evaluate for dysarthria/speech • Inspect tongue for atrophy or fasciculations • Have patient protrude tongue and move side to side • Have patient push tongue against inside of cheek while you palpate externally for strength 47 CRANIAL NERVE (CN) PROCEDURE CN I (olfactory) Test ability to identify familiar aromatic odors, one naris at a time with eyes closed CN II (optic) CN III (oculomotor), CN IV (trochlear), and CN VI (abducens) CN V (trigeminal) CN VII (facial) CN VIII (acoustic) CN IX (glossopharyngeal), and X (vagus) •Test distant and near vision •Perform ophthalmoscopic examination of fundi •Test visual fields by confrontation and extinction of vision •Inspect eyelids for drooping •Inspect pupils' size for equality and their direct and consensual response to light and accommodation. •Test extraocular eye movements •Inspect face for muscle atrophy and tremors •Palpate jaw muscles for tone and strength when patient clenches teeth •Test superficial pain and touch sensation in each branch (test temperature sensation if there are unexpected findings to pain or touch) •Test corneal reflex •Inspect symmetry of facial features with various expressions (e.g., smile, frown, puffed cheeks, wrinkled forehead) •Motor response to blink reflex (sensory CN V) •Test ability to identify sweet and salty tastes on each side of tongue •Test sense of hearing with whisper screening tests or by audiometry •Compare bone and air conduction of sound •Test for lateralization of sound •Test ability to identify sour and bitter tastes on each side of tongue •Test gag reflex and ability to swallow •Inspect palate and uvula for symmetry with speech sounds and gag reflex •Observe for swallowing difficulty •Evaluate quality of guttural speech sounds (presence of nasal or hoarse quality to voice) CN XI (spinal accessory) •Test trapezius muscle strength (shrug shoulders against resistance) •Test sternocleidomastoid muscle strength (turn head to each side against resistance) CN XII (hypoglossal) •Inspect tongue in mouth and while protruded for symmetry, tremors, and atrophy •Inspect tongue movement toward nose and chin •Test tongue strength with index finger when tongue is pressed against cheek •Evaluate quality of lingual speech sounds (l, t, d, n) 48 Sensory System 49 Sensations to Test • Light touch (both pathways) • Pain and temperature (spinothalamic tracts) • Position and vibration (posterior columns) • Discriminative (pathways above plus cortex) 50 Testing • Coordinate findings with motor testing • Before performing the tests below, explain what you are going to do • Patient’s eyes should be closed • Compare symmetry by testing both sides of body 51 Testing • Light touch, pain (sharp v. dull), temperature: – Start distally on hands and feet – Test medially and laterally – Move proximally and map area of deficit • Vibration and position: – Start distally on toes and fingers – Move proximally and map area of deficit 52 Areas for Specific Nerve Roots • • • • • • • Shoulders (C4) Inner and outer forearms (C6 and T1) Thumbs and little fingers (C6 and C8) Anterior thighs (L2) Medial and lateral legs (L4 and L5) Little toes (S1) Medial buttocks (S3) 53 Light Touch • Use wisp of cotton • Avoid touching with pressure • Avoid calloused skin • Anesthesia: absence of sensation • Hypoesthesia: decreased sensation • Hyperesthesia: increased sensation 54 Pain (sharp v. dull) • Alternate sharp and dull – Items to use: • Broken cotton swab or tongue blade • Safety pin • Neurology testing kit – Tell patient first which is which – Clean or discard item before using on new patient • Analgesia: absence of sensation of pain • Hypoalgesia: decreased sensation of pain • Hyperalgesia: increased sensitivity to pain 55 Temperature • Omit if pain sensation intact • If needed, you’ll need two test containers (e.g., test tubes); one filled with hot water and the other cold water • Alternatively you can use something metal like a tuning fork that is heated and chilled under running water 56 Muscle Stretch Reflexes 57 Reflex Testing • Use appropriate reflex hammer • Hold hammer loosely and strike quickly and directly over tendon • Typically performed with patient sitting but can modify if supine 58 Reflex Grading • • • • • 0 = absent 1+ = hypoactive (reduced) 2+ = normal 3+ = hyperactive (increased) 4+ = hyperactive with intermittent or transient clonus – Clonus: involuntary and rhythmic muscular contractions and relaxations • Asymmetrical findings are usually more concerning versus when you observe symmetrically increased, decreased or absent reflexes 59 Reinforcement • If the patient's reflexes are symmetrically diminished or absent, use reinforcement, a technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity • To reinforce the arm reflexes, ask the patient to clench his or her teeth or to squeeze both knees together • If leg reflexes are diminished or absent, ask the patient to lock fingers and pull one hand against the other 60 Biceps Reflex (C5, C6) • The patient's elbow should be partially flexed and the forearm pronated with palm down • Place your thumb or finger firmly on the biceps tendon • Aim the strike with the reflex hammer directly through your digit toward the biceps tendon • Observe flexion at the elbow, and watch for and feel the contraction of the biceps muscle 61 Brachioradialis Reflex (C5, C6) • The patient's hand should rest on the abdomen or the lap, with the forearm partly pronated • Strike the radius with the point or flat edge of the reflex hammer, about 1 to 2 inches above the wrist • Watch for flexion and supination of the forearm 62 Triceps Reflex (C6, C7) • Flex the patient's arm at the elbow, with palm toward the body, and pull it slightly across the chest • Strike the triceps tendon with a direct blow directly behind and just above the elbow • Watch for contraction of the triceps muscle and extension at the elbow • If you have difficulty getting the patient to relax, try supporting the upper arm • Ask the patient to let the arm go limp then strike the triceps tendon 63 Quadriceps (Patellar) Reflex (L2, L3, L4) • The patient may be either sitting or lying down as long as the knee is flexed • Briskly tap the patellar tendon just below the patella • Note contraction of the quadriceps with extension at the knee – Placing your hand on the patient's anterior thigh lets you feel this reflex • There are two options for examining the supine patient – Supporting both knees at once allows you to assess small differences between quadriceps reflexes by repeatedly testing one reflex and then the other – If supporting both legs is uncomfortable for you or the patient, you can place your supporting arm under the patient's leg – Some patients find it easier to relax with this method 64 Quadriceps (Patellar) Reflex (L2, L3, L4) 65 Achilles (Ankle) Reflex (S1) • Sitting – Partially dorsiflex the foot at the ankle – Strike the Achilles tendon, and watch and feel for plantar flexion at the ankle • Supine: – Flex one leg at both hip and knee and rotate it externally so that the lower leg rests across the opposite shin – Then dorsiflex the foot at the ankle and strike the Achilles tendon 66 Motor System 67 Inspection • Body position – During movement and rest • Involuntary movements – Location, quality, rate, rhythm, amplitude – Relation to posture, activity, fatigue, emotion • Muscle bulk (checking for atrophy) – Size and contour 68 Muscle Tone • At rest, muscles should maintain slight tension • If you notice an abnormality, assess muscle resistance to passive stretch • Common findings: – Spasticity: increased with fast movements and at extremes of movement arc – Rigidity: increased no matter rate of movement – Flaccidity 69 Muscle Strength • Must take patient factors into account when assessing (e.g., age, fitness level) • Paresis: impaired strength • Hemiparesis: half of body is weak • Paralysis (-plegia): absent strength – Hemiplegia: one side (upper and lower) is paralyzed – Paraplegia: both legs are paralyzed – Quadriplegia: all four limbs are paralyzed 70 Muscle Strength • Assess by active resistance • Typically test muscles at ≤50% contraction (i.e., don’t try to test a muscle with it completely stretched out) • Example reasons other than strength that patients give way during testing: – Pain – Malingering – Don’t understand the test 71 Muscle Strength • Grading: 0 = no contraction 1 = visible muscle twitch but no movement of the joint 2 = weak contraction insufficient to overcome gravity 3 = weak contraction able to overcome gravity but no additional resistance 4 = weak contraction able to overcome some resistance but not full resistance 5 = expected; able to overcome full resistance • Documented as test grade over expected – “normal” would be 5/5 (read as “five out of five”) 72 Strength Testing • Slides below show isolation of joints and testing each side individually which is most precise • In practice, typically assess both sides at same time and then isolate if you finding weakness • Also more important to be precise if complaint is weakness or muscle fatigue 73 Strength Testing • Elbow: – Flexion: biceps and brachioradialis (C5 and C6) – Extension: triceps (C6, C7, C8) 74 Strength Testing • Wrist extension: extensor carpi radialis longus and brevis (C6, C7, C8, radial nerve) • Grip (C7, C8, T1) 75 Strength Testing • Finger abduction (C8, T1, ulnar nerve) • Thumb opposition (C8, T1, median nerve) 76 Strength Testing • Assess general movement of the trunk but rarely assess specific muscles • Example: – Spine: flexion, extension, lateral bending – Thoracic expansion – Diaphragmatic excursion 77 Strength Testing • Hip: – Flexion: iliopsoas (L2, L3, L4) – Adduction: adductors (L2, L3, L4) • Patient supine with legs flat on bed/table • Place your hands on the medial aspect of the patient’s knees and have them try to bring knees together – Extension: gluteus maximus (S1) • Patient supine with leg raised • Place hand under middle, posterior thigh • Have patient push down toward bed/table 78 Strength Testing • Knee: – Extension: quadriceps (L2, L3, L4) – Flexion: hamstrings (L4, L5, S1, S2) 79 Strength Testing • Foot: – Dorsiflexion: tibialis anterior (L4, L5) – Plantar flexion: gastrocnemius, soleus (S1) 80 Coordination 81 Coordination • Requires integration of four areas: – – – – • Cerebellar system (coordinates movements) Motor system Sensory system Vestibular system To assess, have patient perform the following: – – – – – Rapid alternating movements Point-to-point movements Gait Romberg test Pronator drift 82 Rapid Alternating Movements • Test of cerebellar function • Evaluate: speed, rhythm, and smoothness of movements • Abnormal: – Dysdiadochokinesia: impairment in performance – Adiadochokinesia: complete inability to perform 83 Rapid Alternating Movements • Arms: – Show patient how to strike hand on one thigh, raise, turn over, then strike back of hand • Hands: – Patient taps distal joint of thumb with tip of index finger • Legs: – Patient taps ball of each foot separately – Normal to be slower than hands • Need to be performed as rapidly as possible 84 Point-to-Point Movements • Test position sense and the function of both the labyrinth of the inner ear and the cerebellum (coordinates movement) • Evaluate: accuracy, smoothness, tremor • Abnormal (especially cerebellar disease): heel may overshoot the knee, then oscillate from side to side down the shin 85 Point-to-Point Movements Finger-to-nose test • Patient repeats touching their nose and your index finger Heel-to-shin test • Ask the patient to place one heel on the opposite knee, then run it down the shin to the big toe • Move your finger to patient must change direction and extend arm fully 86 Gait • Have patient walk for several steps and then turn and come back • Observe posture, balance, arm motion, leg motion • Assess the following: – – – – – – • Normal gait Heel-to-toe gait On toes gait On heels gait Hop in place one foot at a time Knee bend Ataxia: uncoordinated, instable gait 87 88 Spastic Hemiparesis • Corticospinal tract lesions – Often seen with stroke • Poor control of flexor muscles during swing • Affected arm is flexed, immobile, and held close to the side, with elbow, wrists, and interphalangeal joints flexed • Affected leg extensors are spastic; ankles are plantar-flexed and inverted • Patients may drag toe, circle leg stiffly outward and forward (circumduction), or lean trunk to contralateral side to clear affected leg during walking 89 Scissors Gait • Spinal cord disease, causing bilateral lower extremity spasticity, including adductor spasm • Seen in spasticity disorders, most commonly cerebral palsy • Gait is stiff and patients advance each leg slowly, and the thighs tend to cross forward on each other at each step • Steps are short • Patients appear to be walking through water, and there may be compensating sway of the trunk away from the side of the advancing leg 90 Steppage Gait • Usually secondary to peripheral motor unit disease • Patients either drag the feet or lift them high, with knees flexed, and bring them down with a slap onto the floor, appearing to be walking up stairs (“foot drop”) • Patients cannot walk on their heels • Gait may involve one or both legs • Tibialis anterior and toe extensors are weak 91 Parkinsonian Gait • Basal ganglia defects of Parkinson disease • Posture is stooped, with flexion of head, arms, hips, and knees • Patients are slow getting started • Steps are short and shuffling, with involuntary hastening (festination) • Arm swings are decreased, and patients turn around stiffly (“all in one piece”) • Postural control is poor 92 Cerebellar Ataxia • Disease of the cerebellum or associated tracts • Gait is staggering and unsteady, with feet wide apart and exaggerated difficulty on turns • Patients cannot stand steadily with feet together, whether eyes are open or closed • Other cerebellar signs are present such as dysmetria (under/over-shoot placement), nystagmus, and tremor 93 Sensory Ataxia • Loss of position sense in the legs from polyneuropathy or posterior column damage • Gait is unsteady and wide based (with feet wide apart) • Patients throw their feet forward and outward and bring them down, first on the heels and then on the toes, with a double tapping sound • Patients watch the ground for guidance when walking • With eyes closed, patients cannot stand steadily with feet together (positive Romberg sign), and the staggering gait worsens 94 Romberg Test • Test for position sense (i.e., proprioception) • Stand next to patient to prevent falling • • Patient stands with feet together with eyes open Once stable, have patient close their eyes and remain standing for 30-60 seconds • Normal findings (Negative Romberg): patient remains upright with minimal swaying Positive Romberg: patient sways/falls without correction • 95 Pronator Drift • Test for corticospinal tract lesion on contralateral hemisphere • Patient stands/sits for 20-30 seconds with eyes closed and both arms straight forward with palms up • Next, tap the arms briskly downward 96 Pronator Drift • Normal: arms return smoothly to the horizontal position • In loss of position sense, the arms drift sideward or upward • In cerebellar incoordination, the arm returns to its original position but overshoots and bounces 97 Specific Exam Maneuvers 98 Meningeal Signs • Test whenever you suspect meningeal inflammation (e.g., meningitis, subarachnoid hemorrhage, encephalitis) • Neck mobility/nuchal rigidity – First, make sure there is no injury or fracture to the cervical vertebrae or cervical cord • In trauma settings, this often requires radiologic evaluation – Then, with the patient supine, place your hands behind the patient's head and flex the neck forward, if possible until the chin touches the chest – Normal: neck is supple, and the patient can easily bend the head and neck forward 99 Meningeal Signs • Brudzinski sign – As you flex the neck, watch the hips and knees in reaction to your maneuver – Normal: hips and knees should remain relaxed and motionless – Positive Brudzinski: flexion of both the hips and knees • Kernig sign – Flex the patient's leg at both the hip and the knee, and then slowly extend the leg and straighten the knee – Normal: no pain to slight discomfort behind the knee during full extension – Positive Kernig: pain and resistance during extension 100 Metabolic Encephalopathy • Example causes: liver disease, uremia, hypercapnia • Asterixis: test in those with mental function impairment • Ask the patient to “stop traffic” by extending both arms, with hands cocked up and fingers spread Watch for 1 to 2 minutes, coaxing the patient as necessary to maintain this position • • Positive asterixis: sudden, brief, nonrhythmic flexion of the hands and fingers followed by recovery – Caused by abnormal function of the diencephalic motor centers that regulate agonist and antagonist muscle tone and maintain posture 101 Winging of the Scapula • Test when the shoulder muscles seem weak or atrophic • Ask the patient to extend both arms and push against your hand or against a wall • Observe the scapulae • Normal: scapulae lie close to the thorax • Positive scapular winging: medial border of the scapula juts backward – Suspicious for weakness of the trapezius or serratus anterior muscle (seen in muscular dystrophy), or injury to the long thoracic nerve. 102 Lumbosacral Radiculopathy • • Straight-Leg Raise Test Positive test: low back pain that radiates down the thigh and leg • Place the patient in the supine position and test each leg separately Raise the patient's relaxed and straightened leg, flexing the thigh at the hip • – Some examiners first raise the patient's leg with the knee flexed, then extend the leg • Assess the degree of elevation at which pain occurs, the quality and distribution of the pain, and the effects of foot dorsiflexion 103 Diabetic Foot Exam • Comprehensive evaluation at least annually for risk of ulcers and amputation – – – – – – – – – – • Poor glycemic control Peripheral neuropathy with loss of protective sensation (LOPS) Cigarette smoking Foot deformities Preulcerative callus or corn PAD History of foot ulcer Amputation Visual impairment DKD (especially patients on dialysis) Every visit (typically every 3 months) should include foot inspection 104 Diabetic Foot Exam • Dermatologic – – – – – • Musculoskeletal – – • Deformity (e.g., claw toes, prominent metatarsal heads, Charcot joint) Muscle wasting (guttering between metatarsals) Neurological assessment – – – – • Skin status: color, thickness, dryness, cracking Sweating Infection: check between toes for fungal infection Ulceration Calluses/blistering 10 g monofilament PLUS one of the following: Vibration using 128 Hz tuning fork Pinprick sensation Temperature Vascular assessment – Foot pulses 105 ADA Foot Care Recommendations • To perform the 10-g monofilament test, place the device perpendicular to the skin • Apply pressure until monofilament buckles • Hold in place for 1 second & release • Perform at the highlighted sites while the patient’s eyes are closed 106 Evaluation of Comatose Patients • Coma: impaired arousal and awareness • Can’t do your “typical” H&P and components below assume you’ve assessed and stabilized the patient’s ABCs • • • Level of alertness (as discussed above) Neurologic exam Interview relatives, friends, others • Multiple scales used for prognosis and severity of coma – Glasgow Coma Scale – FOUR score 107 Example: Glasgow Coma Scale • Score sections and total separately: – Example: E2V3M4 and GCS 9 • Mild brain injury: ≥13 • Moderate injury: 9-12 • Severe brain injury: ≤8 Eye opening Spontaneous 4 Response to verbal command 3 Response to pain 2 No eye opening 1 Best verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 No verbal response 1 Best motor response Obeys commands 6 Localizing response to pain 5 Withdrawal response to pain 4 Flexion to pain 3 Extension to pain 2 No motor response 1 Total 108 Special Reflex Testing 109 Abdominal Reflexes • • • Test by lightly but briskly stroking each side of the abdomen, above (T8, T9, T10) and below (T10, T11, T12) the umbilicus in the direction indicated Use the wooden end of a cotton-tipped applicator, or a tongue blade twisted and split longitudinally Note the contraction of the abdominal muscles and movement of the umbilicus toward the stimulus • If obesity or previous abdominal surgery masks the abdominal reflexes, retract the patient's umbilicus away from the side being tested with your finger and feel for the muscular contraction • Abdominal reflexes may be absent in both central and peripheral nerve disorders 110 Plantar Response (L5 and S1) • • With the wooden end of an applicator stick, stroke the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball Use the lightest stimulus needed to provoke a response, but increase firmness if necessary • • Normal (“negative”): plantar flexion of big toe Positive Babinski response: dorsiflexion of the big toe • Suspect a lesion arising from the CNS affecting the corticospinal tract – • • • Can be transiently positive in unconscious states from drug or alcohol intoxication and during the postictal period following a seizure Some patients withdraw from this stimulus by flexing the hip and the knee Hold the ankle, if necessary, to complete your observation At times it is difficult to distinguish withdrawal from a Babinski response 111 Clonus • • • • Test if the reflexes seem hyperactive Clonus: repetitive rhythmic muscle contraction Sustained clonus points to CNS disease (UMN deficits) Clonus must be present for a reflex to be graded 4 • Ankle – – – – – • Support the knee in a partly flexed position With your other hand, dorsiflex and plantar flex the foot a few times while encouraging the patient to relax, then sharply dorsiflex the foot and maintain it in dorsiflexion Look and feel for rhythmic oscillations between dorsiflexion and plantar flexion Normally the ankle does not react to this stimulus There may be a few clonic beats if the patient is tense or has exercised Other joints may display clonus (e.g., a sharp downward displacement of the patella may elicit patellar clonus in the extended knee) 112 Cremasteric Reflex • Reflex observed in males • Stroke superior and medial part of thigh • Normal response: rise of ipsilateral testis • Absence may indicate: – – – – Testicular torsion Upper and lower motor neuron disorder Spine injury of L1-L2 Ilioinguinal nerve damage 113 Anal Reflex • Using a broken applicator stick or pinprick, lightly scratch the anus on both sides • Watch for reflex contraction of the external anal sphincter • Detection of the reflex contraction is facilitated by placing a gloved finger in the anus during testing • Loss of the anal reflex suggests a lesion in the S2–3–4 reflex arc, seen in cauda equina lesions 114 Special Sensory Examinations 115 Vibration • Test for neuropathy • • Use low-frequency tuning fork (i.e., 128 Hz) Place vibrating for base on DIP joint of fingers and great toe • Must recognize vibration and not just pressure – Have patient tell you when it stops by stopping the vibration while maintaining same pressure • If impaired, proceed proximally over major bony prominences – Wrist, elbow, clavicle – Medial malleolus, shin, patella, anterior superior iliac spine, spinous processes 116 Proprioception • Test for neuropathy • • • • Grasp patient’s great toe by sides Pull it away from other toes Demonstrate “up” and “down” Patient closes eyes and tries to identify position as you move toe • If impaired, move proximally to other joints 117 Discriminative Sensations • Patient needs to have intact touch and position sense for the following tests to be utilized • If touch and position are normal, discriminative sensation impairment indicates a lesion in sensory cortex or posterior column disease 118 Stereognosis • Ability to identify an object by feel • Astereognosis: inability to recognize objects • Place a familiar object in patient’s hand and ask them to identify it • Normal response should be within 5 seconds 119 Graphesthesia • Also called number identification • Utilize if arthritis or other condition prevent stereognosis testing • Use dull object to “draw” a large number on patient's palm • Graphanesthesia: inability to recognize number drawn on palm – Indicates a lesion in sensory cortex 120 Two-Point Discrimination • Use two ends of an opened paper clip, two pins, or special tool • Touch in two places simultaneously alternating with double and single stimuli • Find minimal distance patient can discriminate one point from two • Sensory cortex lesions will cause perceptible distance to widen 121 Point Localization • Briefly touch a point on the patient's skin with their eyes closed • Then ask the patient to open both eyes and point to the place touched • Normally a person can do so accurately • Lesions of the sensory cortex impair the ability to localize points accurately 122 Screening Neurologic Exam 123 Screening Neurologic Exam • Rapid screening when time matters • Used in some protocols for rapid assessment of stroke • Not complete, so will not tell you everything 124 Screening Neurologic Examination • Mental status – – – • Cranial nerves – • – – – Test strength in the following muscles bilaterally: deltoids, triceps, wrist extensors, hand interossei, iliopsoas, hamstrings, ankle dorsiflexors. Test for a pronator drift. Test finger tapping, finger-to-nose, and heel-knee-shin performance. Test tandem gait and walking on the heels. Reflexes – • Test visual fields, pupillary responses to light, eye movements in all directions, facial strength, and hearing to finger rub. Motor system – • Test patients for orientation to person, place, and time. Make sure they can follow at least one complicated command, taking care not to give them any nonverbal cues. If their responses are appropriate and they are able to relate a detailed and coherent medical history, no further mental status testing is necessary (unless they have cognitive complaints). Test plantar responses and biceps, triceps, patellar, and ankle reflexes bilaterally. Sensation – – Test light touch sensation in all four distal limbs, including double simultaneous stimulation. Test vibration sense at the great toes. 125 Documentation 126 Example Documentation • Basic: A&O x 3; CN II-XII grossly intact; sensation intact to light touch, pain, vibration; UE/LE motor strength 5/5 equal bilaterally; DTR 2+ and symmetric UE/LE; gait and movements are coordinated with balance intact 127 Example Documentation • Mental Status: Alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place, and time. Detailed cognitive testing deferred. Cranial Nerves: I—not tested; II through XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar—Rapid alternating movements (RAMs), finger-to-nose (F→N), heel-to-shin (H→S) intact. Gait with normal base. Romberg—maintains balance with eyes closed. No pronator drift. Sensory: Pinprick, light touch, position, and vibration intact. Reflexes: 2 and symmetric with plantar reflexes downgoing. 128 Example Documentation • Mental Status: The patient is alert and tries to answer questions but has difficulty finding words. Cranial Nerves: I—not tested; II—visual acuity intact; visual fields full; III, IV, VI—extraocular movements intact; V motor—temporal and masseter strength intact, corneal reflexes present; VII motor—prominent right facial droop and flattening of right nasolabial fold, left facial movements intact, sensory—taste not tested; VIII—hearing intact bilaterally to whispered voice; IX, X—gag intact; XI—strength of sternocleidomastoid and trapezius muscles 5/5; XII—tongue midline. Motor: strength in right biceps, triceps, iliopsoas, gluteals, quadriceps, hamstring, and ankle flexor and extensor muscles 3/5 with good bulk but increased tone and spasticity; strength in comparable muscle groups on the left 5/5 with good bulk and tone. Gait—unable to test. Cerebellar—unable to test on right due to right arm and leg weakness; RAMs, F→N, H→S intact on left. Romberg—unable to test due to right leg weakness. Right pronator drift present. Sensory: decreased sensation to pinprick over right face, arm, and leg; intact on the left. Stereognosis and two-point discrimination not tested. Reflexes (can record in two ways): 129