Neurological Examination PDF

Nervous system Haitham N.Khalid 24/12/2020 Dr. Haitham Nabeel  Thank you for not sharing this presentation 24/12/2020 Dr. Haitham Nabeel 2 OSCE stuff! The usual orders in nervous system station are: A-perform a motor...

Nervous system Haitham N.Khalid 24/12/2020 Dr. Haitham Nabeel  Thank you for not sharing this presentation 24/12/2020 Dr. Haitham Nabeel 2 OSCE stuff! The usual orders in nervous system station are: A-perform a motor examination of upper limbs B-A-perform a motor examination of lower limbs C-Examine the facial nerve 24/12/2020 Dr. Haitham Nabeel 3 Part of internal medicine The nervous system exam OSCE stations in CA module involves: Part internal medicine OSCE 1-cranial nerve stations 6th grade examination Slides exam in neuroscience module 5th grade 2-examination of motor Generally, a station that system requires many techniques 3-examination of sensory and good practice. system 24/12/2020 Dr. Haitham Nabeel 4  01 Cranial nerves 04 Sensory system 02 Motor system 03 Coordination 24/12/2020 Dr. Haitham Nabeel 5 AR 1 A 23 year old girl presented to the A&E unit with four limb weakness which stated today's morning in the lower limbs and gradually increased, now at the evening she has full weakness in all of her limbs. She repots a similar family history of weakness in her brother but she doesn't know the details of it since he lives abroad. Her vitals are stable, she has no respiratory problem. 24/12/2020 Dr. Haitham Nabeel 6 AR 1 What is the main goal of neurological examination? A-Localize the responsible lesion B-identify the pathology of the responsible lesion C-assess the severity of weakness D-role out a neurological cause E-confirm psychogenic paralysis 24/12/2020 Dr. Haitham Nabeel 7 AR 1 What is the main goal of neurological examination? A-Localize the responsible lesion B-identify the pathology of the responsible lesion C-assess the severity of weakness D-role out a neurological cause E-confirm psychogenic paralysis 24/12/2020 Dr. Haitham Nabeel 8  01 Cranial nerves 24/12/2020 Dr. Haitham Nabeel Cranial nerves I. Olfactory nerve  Present commonly available odors and ask the patient to identify them  Anosmia Vs. parosmia  Olfactory hallucinations are a feature of temporal lobe epilepsy  Anosmia is a feature of parkinson disease 24/12/2020 Dr. Haitham Nabeel 10 II.Optic nerve Involves four steps : 1-visual acuity 2-visual field 3-color vision 4-pupillary reflexes 24/12/2020 Dr. Haitham Nabeel 11 1.Visual acuity Use the snellen chart to test for distant vision Visual acuity is reported as d/D Use reading test types of varying sizes to test for near vision What does a visual acuity of 6/18 mean? 24/12/2020 Dr. Haitham Nabeel 12 2-visual field Confrontation test Testing for peripheral and central fields 24/12/2020 Dr. Haitham Nabeel 13 Visual field defects 24/12/2020 Dr. Haitham Nabeel 14 3-color vision Use ishihara chart to test for color vision 4-pupillary reflexes Examine the pupil for shape and symmetry Look for direct light reflex, consensual light reflex and accomodation reflex 24/12/2020 Dr. Haitham Nabeel 15 III Oculomotor, IV trochlear and VI abducent : Use the H-test LMNL of sixth LMNL of fourth LMNL of third 24/12/2020 Dr. Haitham Nabeel 16 24/12/2020 Dr. Haitham Nabeel 17 Uncal Herniation 24/12/2020 Dr. Haitham Nabeel 18 V trigeminal nerve: Examination of motor component by : Inspection and palpation of masseters and opening the jaw against resistance Examination of sensory component: Light touch and superficial pain in 3 divisions Examination of reflexes Corneal reflex and jaw jerk 24/12/2020 Dr. Haitham Nabeel 19 24/12/2020 Dr. Haitham Nabeel 20 VII facial nerve Blow out the cheek with Motor and sensory mouth closed against component resistance Motor component Close the eyes against examination include: resistance Inspection for any asymmetry Examination of sensory Raise eye brows component : Show his teeth taste on ant. 2/3 of tongue Hyperacusis 24/12/2020 Dr. Haitham Nabeel 21 24/12/2020 Dr. Haitham Nabeel 22  Lesions of facial nerve can be : UMNL LMNL 24/12/2020 Dr. Haitham Nabeel 23 24/12/2020 Dr. Haitham Nabeel 24 24/12/2020 Dr. Haitham Nabeel 25 XI accessory nerve Inspect sternomastoid and trapezius Test the sternomastoid by asking the patient to turn his head against resistance Test the trapezius by asking the patient to shrug his shoulders aginst resistance 24/12/2020 Dr. Haitham Nabeel 26 XII hypoglossal nerve Unilateral LMNL Inspection for fasiculations, Bulbar Vs. pseudobulbar wastig. Protrude the tongue for palsy deviation or abnormal Tremor of tongue is movement common in parkisnson Move tongue from side to side Press against inside of cheek and provide resistance 24/12/2020 Dr. Haitham Nabeel 27 24/12/2020 Dr. Haitham Nabeel 28 AR 2 This 55 year old man with history of DM presented with sudden onset of visual disturbance in the form of double vision. This picture is taken while he is looking to the left. The most likely diagnosis is: A-Left occulomotor nerve palsy B-Left abducent nerve palsy C-Left trochlear nerve palsy D-Left Horner’s syndrome E-Right abducent nerve palsy 24/12/2020 Dr. Haitham Nabeel 29 AR 2 This 55 year old man with history of DM presented with sudden onset of visual disturbance in the form of double vision. This picture is taken while he is looking to the left. The most likely diagnosis is: A-Left occulomotor nerve palsy B-Left abducent nerve palsy C-Left trochlear nerve palsy D-Left Horner’s syndrome E-Right abducent nerve palsy 24/12/2020 Dr. Haitham Nabeel 30  01 Motor system 24/12/2020 Dr. Haitham Nabeel UMN anatomy 24/12/2020 Dr. Haitham Nabeel 32 Motor system This involves : 1-inspection 2-tone 3-power 4-reflexes 24/12/2020 Dr. Haitham Nabeel 33 1-inspection :  Hemiballsimus Size of muscle and any  Athetosis asymmetry  Chorea Fasiculations Involuntary movements  Tremors (fine, coarse at rest, intention)  Dystonia 24/12/2020 Dr. Haitham Nabeel 34 Tremors 24/12/2020 Dr. Haitham Nabeel 35 Abnormal movements 24/12/2020 Dr. Haitham Nabeel 36 2-Tone : It is the resistance felt by examiner when moving a joint passively Hypertonia Vs. hypotonia  Spasticity  Rigidity  Clonus 24/12/2020 Dr. Haitham Nabeel 37 24/12/2020 Dr. Haitham Nabeel 38 Tone abnormalities 24/12/2020 Dr. Haitham Nabeel 39 3-power The scale for muscle power : 0=no muscle contraction 4=joint movement against 1=muscle contraction but with no joint movement gravity and resistance 2=joint movement with gravity 5=normal power 3=joint movement against gravity with no resistance 24/12/2020 Dr. Haitham Nabeel 40 24/12/2020 Dr. Haitham Nabeel 41 24/12/2020 Dr. Haitham Nabeel 42 4-reflexes Required reflexes are : 1-biceps jerk (C5,C6) 2-triceps jerk (C6,C7) 3-supinator jerk (C5,C6) 4-knee jerk (L3,L4) 5-ankle jerk (S1) 6-babiniski (plantar reflex) 24/12/2020 Dr. Haitham Nabeel 43 24/12/2020 Dr. Haitham Nabeel 44  Grading the reflex : 0=absent 1=present 2=brisk 3=very brisk 4=clonus 24/12/2020 Dr. Haitham Nabeel 45 AR 3 The abnormal findings during muscle tone examination NOT include: A-calsp knife phenomenon is unique for parkinsonisim B-sustained clonus more than three beats is considered pathological C-flaccidity is usually related to pathological involvement aof lower motor neurons D-spasticity is caused by an UMNL 24/12/2020 Dr. Haitham Nabeel 46 AR 3 The abnormal findings during muscle tone examination NOT include: A-calsp knife phenomenon is unique for parkinsonisim B-sustained clonus more than three beats is considered pathological C-flaccidity is usually related to pathological involvement aof lower motor neurons D-spasticity is caused by an UMNL 24/12/2020 Dr. Haitham Nabeel 47  01 UMNL vs. LMNL 24/12/2020 Dr. Haitham Nabeel UMNL vs. LMNL 24/12/2020 Dr. Haitham Nabeel 49 EBM 24/12/2020 Dr. Haitham Nabeel 50  01 Coordination 24/12/2020 Dr. Haitham Nabeel AR 4 Coordination is examined by which of the following: A. Snout reflex B. Heel to shin test C. Hoffman’s test D. Glabellar tap E. Knee reflex 24/12/2020 Dr. Haitham Nabeel 52 AR 4 Coordination is examined by which of the following: A. Snout reflex B. Heel to shin test C. Hoffman’s test D. Glabellar tap E. Knee reflex 24/12/2020 Dr. Haitham Nabeel 53 Coordination Speech ability Romberg test Finger to nose test Rapid alternating movements Rebound phenomena Heal to shin test Nystagmus 24/12/2020 Dr. Haitham Nabeel 54 24/12/2020 Dr. Haitham Nabeel 55  01 Sensory system 24/12/2020 Dr. Haitham Nabeel Sensory system Light touch Stereognosis and Superficial pain graphesthesia Temperature Sensory inattention Vibration Joint position sensation Two point discrimination 24/12/2020 Dr. Haitham Nabeel 57 24/12/2020 Dr. Haitham Nabeel 58 24/12/2020 Dr. Haitham Nabeel 59 AR 5 Signs of UMNL Not include : A-hyperreflexia B-proximal muscle weakness C-spasticity D-loss of superficial abdominal reflexes 24/12/2020 Dr. Haitham Nabeel 60 AR 5 Signs of UMNL Not include : A-hyperreflexia B-proximal muscle weakness C-spasticity D-loss of superficial abdominal reflexes 24/12/2020 Dr. Haitham Nabeel 61 Case Scenario Examination of the motor system of the upper limbs had shown that the patient was lying in dorsal decubitus posture with flaccid left arm. Fasciculations had been provoked by flicking the skin over the deltoid muscles. There was wasting of the muscles of the whole left upper arm. The right upper arm shows normal position, normal muscle bulk, and no involuntary movements. The muscle tone of the left arm was decreased (hypotonia, flaccid) while the right arm had normal muscle tone with no hypertonia, hypotonia, or paratonia. Grade o (very weak) muscle power of the left arm; the right arm power was full and grade five at the fingers, wrist, elbow, and shoulder. The triceps, biceps, and supinator reflexes of the left arm were absent even with reinforcement (grade 0); two pluses (average or normal) triceps reflex, biceps reflex, supinator reflex, and finger reflex of the right arm. Cerebellar coordination tests can not be elicited in the left arm because of weakness; the right side had accepted cerebellar coordination with no intension tremor, no overshooting, no dyssynergia, no dysdiadochokinesis, and no rebound phenomenon. 24/12/2020 Dr. Haitham Nabeel 62 Case Scenario Examination of the motor system of the upper limbs had shown that the patient was lying in dorsal decubitus posture with flaccid left arm. Fasciculations had been provoked by flicking the skin over the deltoid muscles. There was wasting of the muscles of the whole left upper arm. The right upper arm shows normal position, normal muscle bulk, and no involuntary movements. The muscle tone of the left arm was decreased (hypotonia, flaccid) while the right arm had normal muscle tone with no hypertonia, hypotonia. Grade o (very weak) muscle power of the left arm; the right arm power was full and grade five at the fingers, wrist, elbow, and shoulder. The triceps, biceps, and supinator reflexes of the left arm were absent even with reinforcement (grade 0); two pluses (average or normal) triceps reflex, biceps reflex, supinator reflex, and finger reflex of the right arm. Cerebellar coordination tests can not be elicited in the left arm because of weakness; the right side had accepted cerebellar coordination with no intension tremor, no overshooting, no dyssynergia, no dysdiadochokinesis, and no rebound phenomenon 24/12/2020 Dr. Haitham Nabeel 63  KEEP CALM COS WE ARE FINISHED 24/12/2020 Dr. Haitham Nabeel 64  MED ACE MEDICAL COURSES THANK YOU! Lecture design: Dr. Fatima Ausama +9647807170489 [email protected] Do you have any questions? 24/12/2020 Dr. Haitham Nabeel 65