Neurological Examination PDF

NEUROLOGICAL EXAMINATION Ghadeer Fatani, MD,APBN  LEARNING OBJECTIVES Become familiar with neurologic exam and how to interpret normal or abnormal findings. Identify neuroanatomical function and clinical localization in relation to the neurologic exam. ...

NEUROLOGICAL EXAMINATION Ghadeer Fatani, MD,APBN  LEARNING OBJECTIVES Become familiar with neurologic exam and how to interpret normal or abnormal findings. Identify neuroanatomical function and clinical localization in relation to the neurologic exam.  WHY Does the patient who just collapsed on the street have cardiac disease or an intracranial bleeding ? Does the patient with nausea and vomiting need a gastroenterology consult, a head CT or emergency interventions to lower dangerously elevated intracranial pressure ?  NEUROLOGICAL EXAM SUBDIVISIONS Mental status Cranial nerves Motor exam Reflexes Coordination and gait Sensory exam  MENTAL STATUS LEVEL OF ALERTNESS, ATTENTION AND COOPERATION BRAINSTEM AND RETICULAR FORMATION, BILATERAL LESIONS OF THALAMI/CEREBRAL HEMISPHERES. UNILATERAL CORTICAL/THALAMIC LESION DOCUMENT RESPONSE TO WHICH STIMULI, CHECK ATTENTION BY ASKING PT TO SPELL FORWARD AND BACKWARD, DOCUMENT LEVEL OF COOPERATION ORIENTATION THE CAVEAT OF USING A&O X 3. FOR COMPROMISED MENTAL STATE, DOCUMENT MORE SPECIFICALLY MEMORY RECENT MEMORY : 3 ITEM RECALL, REPETITION OR DELAYED RECALL LIMB MEMORY STRUCTURES AT MEDIAL TEMPORAL LOBE AND MEDIAL DIENCEPHALON LONG TERM MEMORY : HISTORICAL/VERIFIABLE PERSONAL EVENTS ANTEROGRADE VS RETROGRADE AMNESIA  MENTAL STATUS ‫الطالقة‬ LANGUAGE DOMINANT HEMISPHERE : BROCA’S AREA (FLUENCY), WERNICKE’S AREA (COMPREHENSION), SUBCORTICAL WHITE MATER AND GRAY MATTER STRUCTURE (THALAMUS AND CAUDATE NUCLEUS) WHAT TO TEST? SPONTANEOUS SPEECH, COMPREHENSION, NAMING, REPETITION, READING AND WRITING APRAXIA ABNORMALITIES IN MOTOR CONCEPTUALIZATION, PLANNING AND EXECUTION CAUSED BY DIFFUSE LESIONS OF THE CORTEX NEGLECT AND CONSTRUCTIONS ‫اإلهمال واإلنشاءات‬ NON DOMINANT PARIETAL LOBE HEMI-NEGLECT, ANOSOGNOSIA SOMATOSENSORY, VISUAL AND AUDITORY  MENTAL STATUS LOGIC AND ABSTRACTION ABILITY TO SOLVE A SIMPLE PROBLEM, HIGHER ORDER ASSOCIATION CORTEX. DELUSIONS AND HALLUCINATIONS TOXIC METABOLIC ABNORMALITIES, PRIMARY PSYCHIATRIC DISORDER ABNORMAL SENSORY PHENOMENA : VISUAL, SOMATOSENSORY OR AUDITORY CORTEX THOUGHT DISORDER : ASSOCIATION CORTEX AND LIMBIC SYSTEM MOOD CRANIAL NERVES  CRANIAL NERVES OLFACTION (CN I) DON’T USE NOXIOUS ODOR OR IT WILL STIMULATE PAIN FIBERS SUBFRONTAL CORTEX, OLFACTORY NERVES IN NASAL MUCOSA, DAMAGE TO CRIBRIFORM PLATE OR INTRACRANIAL LESIONS AFFECTING OLFACTORY BULB  CRANIAL NERVES VISION (CN II) VISUAL ACUITY COLOR VISION RED DESATURATION VISUAL FIELD VISUAL EXTINCTION FUNDOSCOPY (CN II) : RETINA, RETINA VESSELS, OPTIC NERVE ATROPHIC CHANGES, PAPILLAEDEMA.  CRANIAL NERVES PUPILLARY RESPONSES (CN II,III) DIRECT RESPONSE CONSENSUAL RESPONSE ACCOMMODATION  CRANIAL NERVES EXTRAOCULAR MOVEMENTS (CN III, IV and VI) SMOOTH PURSUIT CONVERGENCE SACADES Horizontal gaze center  CRANIAL NERVES MUSCLES OF FACIAL EXPRESSION AND TASTE (CN VII) FACIAL WEAKNESS CAN BE CAUSED BY LESION OF UMN IN THE CONTRALATERAL MOTOR CORTEX OR DESCENDING CNS PATHWAYS, LMN IN THE IPSILATERAL FACIAL NERVE NUCLEUS OR EXITING NERVE FIBERS, THE NMJ OR THE FACIAL MUSCLES. UMN FOR UPPER FACE PROJECT TO FACIAL NUCLEI BILATERALLY. UNILATERAL TASTE DEFICITS OCCUR IN LESIONS OF LATERAL MEDULLA INVOLVING NUCLEUS SOLITARIUS OR LESION OF FACIAL NERVE  MOTOR EXAM OBSERVATION (TREMORS, FASCICULATION, INVOLUNTARY MOVEMENTS, ATROPHY) PALPATION FOR TENDERNESS TONE POWER PRONATOR DRIFT, RAPID FINGER TAP GRADING PATTERN OF WEAKNESS MUSCLE POWER SCALE  REFLEXES DEEP TENDON REFLEXES GRADING (0 TO 4) KNOW HOW TO REINFORCE IT UMN VS. LMN REMEMBER HOW IT’S BEING INFLUENCED BY METABOLIC FACTORS (THYROID, MG), PT’S ANXIETY DEEP TENDON REFLEXES GRADING  COORDINATION Finger to nose testing Rabid alternating movement Heel to shin movement  GAIT HEMIPLEGIC GAIT DIPLEGIC GAIT/CEREBRAL PALSY GAIT (SCISSORING) PARKINSONIAN GAIT (FESTINATING GAIT) GAIT APRAXIA (MAGNETIC GAIT) ROMBERG TEST CEREBELLAR/ATAXIC GAIT HIGH STEPPAGE GAIT WADDLING GAIT CHOREIFORM GAIT https://youtu.be/FFki8FtaByw  SENSORY EXAM PAIN, TEMPERATURE LIGHT TOUCH, PROPRIOCEPTION/JOINT POSITION, VIBRATION SENSORY LEVEL/DERMATOME – SPINAL CORD BE MINDFUL OF THE TRACT THAT YOU ARE TESTING  TAKE HOME MESSAGES A picture-better yet, a moving picture- is worth thousand words. Practice, practice, practice. https://www.youtube.com/watch?v=L4t1Mc_mWQk