Clinical Propedeutics: Neurological Exploration PDF (2024-2025)

CLINICAL PROPEDEUTICS NEUROLOGICAL EXPLORATION 2024-2025 Marta Torres Torrillas Medicine and Surgery Department [email protected]  INTRODUCTION WHAT IS THE MAIN WHAT IS IT? OBJECTIVE?...

CLINICAL PROPEDEUTICS NEUROLOGICAL EXPLORATION 2024-2025 Marta Torres Torrillas Medicine and Surgery Department [email protected]  INTRODUCTION WHAT IS THE MAIN WHAT IS IT? OBJECTIVE? Systematic and orderly evaluation of To answer the following questions: the functionality of the nervous + Is the injury affecting the system nervous system? + PNS + Where is the lesión located? + CNS + What is the degree of severity of the injury? + Have the injury get worse, better or persist?  INTRODUCTION WHAT ARE WE GOING TO NEED? Light Mosquito Percussion hammer Formulary  INTRODUCTION: CNS BRAIN: centre of conscious decision-making. Involve in learning, character and emotions CEREBELLUM: involved in movement and motor control. Involved in body posture, coordination and balance BRAINSTEAM: connects the brain with the spinal cord. It regulates vital body functions such as breathing or heart rate INTRODUCTION: CNS SPINAL CORD: contains nerve bundles and cells that carry messages from the brain to the body. It conttrols body movements, report senses to the brain and manage the reflexes.  The spinal cord is divided into segments: + 8 cervical INTRODUCTION:CNS + 13 thoracic + 7 lumbar + 3 sacral + 5 caudal NEUROLOGICAL EXPLORATION Mental Posture Postural Cranial Spinal status Pain and gait reactions nervs reflexes NEUROLOGICAL EXAM: MENTAL STATUS Assessment of the level of consciousness and response to the environment Alert: normal response Depression: decreased response Disorientation: inappropriate response Stupor: no response to normal stimuli and weak response to painful stimuli Coma: lack of response to any type of stimulus NEUROLOGICAL EXAM: POSTURE HEAD COLUMN EXTREMITIES Rotation Kyphosis Wide base station Torsion Lordosis Knuckle support Ventroflexion Scoliosis Lying or sitting NEUROLOGICAL EXAM: POSTURE NEUROLOGICAL EXAM: POSTURE  NEUROLOGICAL EXAM: GAIT The following structures are implicated in normal gait: + Peripheral nerves: motor and sensory + Spinal cord + Brainstem + Cerebellum The ATAXIA is a neurological sign that manifests in a lack of coordination in the gait. It is a clinical finding and not a disease. NEUROLOGICAL EXAM: GAIT ATAXIA: the lesion can be in peripheral sensory nerves, spinal cord, brainstem, cerebellum or vestibular system. There are differet types of ataxia: PROPIOCEPTIVE: drags limbs, walks on knuckles CEREBELLAR: Dysmetry (different range and strenght for each step). Two different types: + HYPERMETRY: Exaggerated limbs’ movements, excessive flexion and extension + HYPOMETRY: Reduced limbs’ flexion and extension VESTIBULAR: Head tilting and turning while walking, walking in circles NEUROLOGICAL EXAM: GAIT NEUROLOGICAL EXAM: GAIT NEUROLOGICAL EXAM: GAIT NEUROLOGICAL EXAM: GAIT NEUROLOGICAL EXAM: GAIT NEUROLOGICAL EXAM:GAIT NEUROLOGICAL EXAM: GAIT NUMBER OF LIMBS AFFECTD DEGREE OF IMPACT MONO-: One limb -PARESIS: Weakness or reduced motor function due to neurological or PARA-: Hind limbs myopathic causes TETRA-:Four limbs -PLEGIA: Total loss of voluntary HEMI-: Both limbs on the same side movement NEUROLOGICAL EXAM: GAIT NEUROLOGIAL EXAM: GAIT NEUROLOGICAL EXAM: GAIT NEUROLOGICAL EXAM: POSTURAL REACTIONS Postural reactions are responsable for the subconscious maintenance of the body’s posture when movement and position is altered. They ensure that the body remains aligned. The propioception is the notion of the situation and postures of the different parts of the dody, with or without the intervention of the vision. It involves both the central and periphereal nervous system. Postural defects: + Brain injury: opposite side of the postural defect + Spinal cord injury: same side postural defect NEUROLOGICAL EXAM: POSTURAL REACTIONS PAW REPLACEMENT Animal resting on all four limbs. Flex the fingers of one limb so that the back of the fingers rest on the table must reposition the limb in less than 3 seconds PAW REPLACEMENT ANIMAL RESTING ON ALL FOUR LIMBS. FLEX THE FINGERS OF ONE LIMB SO THAT THE BACK OF THE FINGERS REST ON THE TABLE MUST REPOSITION THE LIMB IN LESS THAN 3 SECONDS NEUROLOGICAL EXAM: POSTURAL REACTIONS HEMIWALKING REACTION Animal in station. Keeping EE from same side up. The limbs that are resting must move simmetrically NEUROLOGICAL EXAM: POSTURAL REACTIONS EXTENSOR POSTURAL THRUST Keep the animal with the forelimbs raised. Perform forward movement. The animal extends the hind limbs before contacting the ground, then it moves caudally to achieve a correct position. NEUROLOGICAL EXAM: POSTURAL REACTIONS VISUAL OR TACTILE PLACING REACTION First without vision, then with vision Approach the animal to the table slowly Normal response: immediately placement of the feet on the table NEUROLOGICAL EXAM: POSTURAL REACTIONS WHEELBARROWING Raising the hind limbs the limbs in support should move symmetrically when pushing the animal. WHEELBARROWING Raising the hind limbs the limbs in support should move symmetrically when pushing the animal. NEUROLOGICAL EXAM: POSTURAL REACTIONS HOPING Rise three limbs Push the animal in the direction of the limb that is in contact with the floor HOPING Rise three limbs Push the animal in the direction of the limb that is in contact with the floor  NEUROLOGICAL EXAM: CRANIAL NERVES Cranial nerves innervate different structures in the head, neck, and trunk. The olfactory and optic nerves exit from the cerebrum, while the remaining cranial nerves exit from the brainstem. Abnormalities in cranial nerve function help localize the lesion to a specific level of the brain or brainstem. Cranial nerves have motor, sensory, and autonomic functions. Generally, a singular cranial nerve deficit indicates a peripheral nerve lesion. A lesion in the brainstem may produce multiple cranial nerve deficits and motor and sensory abnormalities of the extremities.  I. OLFATORY  II. OPTIC  III. OCULOMOTOR  IV. TROCHLEAR  V. TRIGEMINAL  VI. ABDUCENS  VII. FACIAL  VIII.VESTIBULOCOCHLEAR  IX. GLOSOFARYNGEAL  X. VAGUS  XI. ACCESSORY  XII. HYPOGLOSSSAL NEUROLOGICAL EXAM: CRANIAL NERVES OPTIC: HABILITY TO FOLLOW OBJECTS (II, III, IV y VI) OLFATORY (I)  MENACE RESPONSE (II y VII) Bring one hand or two fingers towards the eye and observe the blinking. Each eye independently (cover the other). Do not touch the eyelid or fimbriae or move air. It is not a reflex Learnt at 10-12 weeks old NEUROLOGICAL EXAM: CRANIAL NERVES  NEUROLOGICAL EXAM: CRANIAL NERVES DIRECT-INDIRECT PUPILARY REFLEX (II y III) Direct R.: contracts the pupil of the eye that receives the visual stimulus Indirect R.: contract the pupil of the opposite eye NEUROLOGICAL EXAM: CRANIAL NERVES PUPILS, EYELIDS AND EYEBALL POSITION (III, IV y VI) The size and symmetry of the pupil, the opening of the eyelids. Observe the position and movement of the eyeballs NEUROLOGICAL EXAM: CRANIAL NERVES POSITIONAL NISTAGMUS (III, IV, VI y VIII) Move the head to the left, right, up, and down. Two to three rhythmical beats of the eyeballs should be observed with a fast phase in the direction of the movement (normal physiologic nystagmus) NEUROLOGICAL EXAM: CRANIAL NERVES PALPEBRAL REFLEX (V y VII) Touching the lid edge the animal must close the eye NEUROLOGICAL EXAM: CRANIAL NERVES MASSETER AND TEMPORAL MUSCLES (V) Palpate these muscles to assess for atrophy. Atrophy indicates a trigeminal motor injury NEUROLOGICAL EXAM: CRANIAL NERVES MANDIBULAR TONE AND ROM (V) Open the jaw to assess muscle tone and range of motion. Reduced muscle tone indicates a lesion of the trigeminal motor portion. Reduced range of motion usually indicates muscle disease. NEUROLOGICAL EXAM: CRANIAL NERVES AURICULAR REFLEX (VII) Tickle inside the pinna to see the movement. NEUROLOGICAL EXAM: CRANIAL NERVES BUCAL REFLEX (V and VII) Pinch the lip to assess the movement or withdrawal of the animal. NEUROLOGICAL EXAM: CRANIAL NERVES SWALLOWING REFLEX (IX, X and XII) Induce swallowing by external or internal palpation of the pharynx NEUROLOGICAL EXAM: CRANIAL NERVES TONGUE (XII) Appropriate movement and strength, palpate it for atrophy or hypertrophy NEUROLOGICAL EXAM: CRANIAL NERVES TRAPEZIUS MUSCLE (XI) Palpate the trapezius muscle for atrophy  The spinal reflexes are stereotyped motor outputs caused by certain afferent inputs. They involve neural circuitry that is only found in the spinal cord. Involve peripheral nerves and specific spinal segments Relaxed animal in lateral decubitus A percussion hammer and mosquito are needed ALTERATIONS: Decreased: hyporeflexia Absence: areflexia Increase: hyperreflexia NEUROLOGICAL EXAM: SPINAL REFLEXES NEUROLOGICAL EXAM: SPINAL REFLEXES ANTERIOR LIMB: PELVIC LIMB: ❖BICEPS REFLEX (C6-C8) ❖PATELLAR REFLEX (L4-L5) ❖TRICEPS REFLEX (C7-T1) ❖GASTROCNEMIUS REFLEX (L7- ❖ EXTENSOR CARPI RADIALIS S1) REFLEX (C7-T2) ❖CRANIAL TIBIAL REFLEX (L6- ❖WITHDRAWAL REFLEX (C6-T2) S2) ❖PERINEAL REFLEX (S1-S3) ❖WITHDRAWAL REFLEX ( L4-S3) CUTANEOUS TUNICI MUSCLE REFLEX (T2-L5) NEUROLOCICAL EXAM: SPINAL REFLEXES Biceps reflex Place a finger on the biceps tendon and percuss the finger. A brief elbow flexion indicates a normal biceps reflex (C6–C8). The response can be subtle in healthy dogs and cats. NEUROLOGICAL EXAM: SPINAL REFLEXES Triceps reflex Place a finger on the triceps tendon and percuss the finger. A brief elbow extension indicates a normal triceps reflex (C7– T2). The response can be subtle in healthy dogs and cats. NEUROLOGICAL EXAM: SPINAL REFLEXES Extensor carpi radialis muscle reflex Directly percuss the muscle. A brief extension of the carpus indicates a normal extensor carpi radialis muscle reflex (C7–T2)  NEUROLOGICAL EXAM: SPINAL REFLEXES Withdrawal reflex Pinch the toe with fingers or forceps. Flexion of all thoracic limb joints indicates a normal withdrawal reflex (C7–T2).  NEUROLOGICAL EXAM: SPINAL REFLEXES Crossed extensor reflex When the withdrawal reflex is elicited, there should be no obvious extension of the opposite limb; such extension is a crossed extensor reflex, indicating a lesion between the brain and C5. NEUROLOGICAL EXAM: SPINAL REFLEXES Patellar reflex Percussing the patellar tendon and observing a brief extension of the stifle joint indicates a normal patellar reflex (L4–L5) NEUROLOGICAL EXAM: SPINAL REFLEXES Gastrocnemius muscle reflex Grasp the gastrocnemius muscle between the thumb and forefinger and percuss the thumb. A brief hock extension indicates a normal gastrocnemius muscle reflex (L6–S2) NEUROLOGICAL EXAM: SPINAL REFLEXES Cranial tibial muscle reflex Percussing the cranial tibial muscle directly and observing a brief flexion of the hock indicates a normal cranial tibial muscle reflex (L6–S2). NEUROLOGICAL EXAM: SPINAL REFLEXES Withdrawal reflex Pinching the toe with fingers or forceps and observing flexion of the joints of the pelvic limb indicates a normal withdrawal reflex (L7–S2).  NEUROLOGICAL EXAM: SPINAL REFLEXES Crossed extensor reflex Extension of the opposite limb when the withdrawal reflex is elicited is a crossed extensor reflex, which is seen with a lesion between the brain and L5.  NEUROLOGICAL EXAM: SPINAL REFLEXES Anal reflex Pinching the perineal area with a finger or forceps and observing contraction of the anal sphincter indicates that the anal reflex (S1–3) is present. If the tail simultaneously pulls down, this indicates the anal/caudal reflex (S1–Cd5) is present. NEUROLOGICAL EXAM: SPINAL REFLEXES Cutaneous trunci muscle response (panniculus) Pinching the skin with hemostatic forceps and observing contraction of the cutaneous trunci muscles indicates a normal cutaneous trunci muscle response (T2–L5). Superficial sensation is observed if the animal turns to look, cries, or growls. NEUROLOGICAL EXAM: PAIN At the end of the neurological examination ALTERATIONS ❖ HYPERESTHESIA: exaggerated reaction to normal or weak stimuli. ❖ HYPOESTHESIA: slow or superficial response to strong stimuli. ❖ ANESTHESIA: total loss of sensation ANY DOUBTS?