Neurological Examination Surat Tanprawate, MD, MSc(Lond.), FRCPT Division of Neurology, Chaing Mai University
Thursday, December 15, 2011
Brain function
Thursday, December 15, 2011
Brain function
Thursday, December 15, 2011
Neurological skill • Chief complaint • History taking • Neurological examination • screening neurological examination • focused neurological examination • Consequence of the exam • Skill and method Thursday, December 15, 2011
Aim of neurological exam • •
To localized the lesion Central vs Peripheral nervous system
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symmetrical vs asymmetrical
If central: cerebrum, midbrain, spinal cord If peripheral, is it: nerve, muscle, NMJ
Equipment • • • •
Penlight
•
Cotton wisp
Tongue blade Tuning fork Familiar objects(coin, key, paper clip)
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• • •
Reflex hammer Aromatic substances Test tubes of hot and cold water
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Consequence of Neurologic Exam •
Mental status
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Consciousness: Level of consciousness, orientation Higher cortical function
Cranial nerves Motor system Reflex Sensory Coordination Gait and balance
Special test
Consciousness Higher cortical function : content of consciousness : awareness : orientation; time, place, person : higher cortical function : Mini-mental state examination
Ascending Reticular Activating System(ARAS) : level of consciousness : wakefulness : stimuli and response : Glasglow Coma Score(GCS)
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Level of consciousness • Wakefulness • Drowsiness • Semi-coma • Coma Thursday, December 15, 2011
Glasglow Coma Score (GCS)
• Eye response • Verbal response • Motor response
Thursday, December 15, 2011
First published in 1974 by Graham Teasdale and Bryan J. Jennett, Professor of neurosurgery University of Glascow
Glasglow Coma Score (GCS)
E
1. No eye opening 2. Eye opening in response to pain (Patient fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.) 3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.) 4. Eyes opening spontaneously
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Glasglow Coma Score (GCS)
V
1. No verbal response 2. Incomprehensible sounds. (Moaning but no words.) 3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange) 4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.) 5. Oriented (Patient responds coherently and appropriately to questions such as the patientʼs name and age, where they are and why, the year, month, etc.)
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Glasglow Coma Score (GCS)
M
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1.
No motor response
2.
Extension to pain (abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate posture)
3.
Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate posture)
4.
Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5.
Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supraorbital pressure applied.)
6.
Obeys commands. (The patient does simple things as asked.)
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Consciousness • Impairment of self awareness, person, environment, time
• Clouding of consciousness • Confusional state •
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acute(delirium), chronic(severe dementia)
Consciousness Level(arousal) and content(awareness) of consciousness
Arousal and awareness, the two components of consciousness in coma, vegetative state, minimally conscious state, and locked-in syndrome. Thursday, December 15, 2011
Higher Cortical Function • Memory • Language • Calculation • Higher motor function(Praxis) • Higher sensory function(Gnosis) Thursday, December 15, 2011
Memory • Short term memory • ถามคําให้ทวน 3 คํา “ต้นไม้ รถยนต์ มือ” • Long term memory • ชื่อประเทศ ชื่อพ่อแม่ Thursday, December 15, 2011
Language • • • • • • Thursday, December 15, 2011
Fluency: ความคล่องของการพูด Comprehension: 1 step, 2 step, 3 step Repetition “ยายพาหลาน ไปซื้อขนมที่ตลาด” Naming: ปากกา นาฬิกา แก้วน้ํา Reading Writing
Aphasia • Aphasia refers to an impairment in
linguistic communication produced by brain dysfunction
• It must be distinguished from other
disorders of verbal output such as dysarthria, mutism, and the abnormal language production of patients with thought disorder
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transcortical motor aphasia
Transcortical sensory aphasia
Motor aphasia
A: Wernicke's area B: concept center M: Broca's area a--> A -auditory input to Wernicke's area M --> m -motor output from Broca's area A --> M -tract connecting Wernicke's and Broca's areas A --> B -pathway essential for understanding spoken input B --> M -pathway essential for meaningful verbal output. Thursday, December 15, 2011
Sensory aphasia Conduction aphasia
Articulatory disorder (aphemia)
Pure word deafness
Lichtheim's diagram of the language system
Praxis
Gnosis
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Mini-Mental State Examination (MMSE)
Thursday, December 15, 2011
Cranial nerve
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Olfactory nerve (CN I) •
Test each nose with familiar nonirritate smell
•
Thursday, December 15, 2011
Coffee bean
Optic nerve (CN II) • Visual acuity • Visual field • Fundoscopy • Swinging flashlight test Thursday, December 15, 2011
Visual acuity •
Using hand held card (14 inches) or snellen wall chart, assess each eye separately
•
Direct patient to read aloud line with smallest lettering that theyʼre able to see
Thursday, December 15, 2011
Visual acuity: Assessment •
20/20 = patient can read at 20` with same accuracy as person with normal vision.
•
20/400 = patient can read at 20` what normal person can read from 400` (i.e. very poor acuity).
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Visual field
Thursday, December 15, 2011
Pupillary response Direct light reflex Consensual light reflex
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Fundoscopic examination
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Cranial nerve III, IV, VI Extraocular movement
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Trigeminal nerve (CN V)
• Facial sensation • Motor: jaw strength and muscle bulk
• Corneal reflex Thursday, December 15, 2011
Masseter test
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Corneal Reflex
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Facial nerve (CN VII) “Tear, Ear, Taste, Face”
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Rinne test
Weber test
Vestibulocochlear nerve (CN VIII) Thursday, December 15, 2011
Vagus nerve (CN X)
A normal soft palate is illustrated on the left. On the right, a right palatal palsy from a lower motor neuron X nerve lesion has resulted in deviation of the uvula to the left.
Thursday, December 15, 2011
Hypoglossus nerve (CN XII)
Motor examination • Muscle bulk • Muscle fasciculation/cramp • Muscle tone • Muscle strength Thursday, December 15, 2011
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Reflex
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Reflex Superficial Reflexes
• Plantar reflex • Stroke lateral side of foot from heel to the ball, then across to the medial side
• Normal response is a positive plantar reflex
• Plantar flexion of all toes • Abnormal response is the Babinski sign in those 2 yoa
• Dorsiflexion of the great toe with or without fanning of the other toes Thursday, December 15, 2011
Sensory function
Thursday, December 15, 2011
Sensory function •
Primary sensory functions
• •
Always with the personʼs eyes closed Sites
• • • • • • Thursday, December 15, 2011
Vision, hearing, smell, taste, and facial sensation Hands Lower arms Abdomen Feet Lower legs
Sensory function •
Primary sensory functions
•
Superficial touch
• •
•
Sharp and dull sensations Allow 2 seconds between each stimulus
Temperature and deep pressure
• Thursday, December 15, 2011
Have the person point to the area touched
Superficial pain
• •
•
Use a cotton wisp
ONLY USED when superficial pain sensation is not intact
Sensory function •
Primary Sensory Functions
•
•
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Vibration
• • •
Place stem of tuning fork against bony prominences Begin distally Sites
• • •
Sternum Finger – wrist – elbow - shoulder Toes – ankle – shin
Position of joints (great toes, one finger on each hand)
• •
Up Down
Proprioception •
Proprioception
• •
The sensation of position and muscular activity originating from within the body which provides awareness of posture, movement, and changes in equilibrium
Test
• • Thursday, December 15, 2011
Joint position test Rombergʼs test
Sensory function •
Cortical Sensory Functions
• •
Always with the personʼs eyes closed Stereognosis
•
Ability to identify a familiar object by touch and manipulation
•
•
Graphesthesia
• •
Thursday, December 15, 2011
Tactile agnosia: inability to recognize objects
With a blunt pen, draw a letter or number on the palm Should be readily recognized
Sensory function •
Cortical Sensory Functions
•
Point location
•
Touch an area of the body and ask the person to point to where you have touched
•
•
Extinction phenomenon
• • Thursday, December 15, 2011
This is being tested the same time as superficial touch
Simultaneously touch one or both sides of the body Ask the person to point to where you have touched
Sensory function •
Cortical sensory functions
•
Two-point discrimination
•
Use two pointed objects, alternate touching skin with one or two points
•
Find the distance at which the person can no longer discriminate 2 point
• • • • • Thursday, December 15, 2011
Finger tip Toes Palms Forearms Upper arms and thighs
2-8 mm 3-8 mm 8-12 mm 40 mm 75 mm
Cerebellar function • Coordination and fine motor skill •
Thursday, December 15, 2011
Rapid rhythmic alternating movement
•
Have seated person alternately pronate and supinate hands, patting knees, and gradually increasing speed OR
•
Have person touch thumb to each finger on the same hand sequentially from index to little finger and back, gradually increasing speed
•
person should be able to do these movements smoothly, maintaining rhythm, with increasing speed
•
Observe for slow, stiff, non-rhythmic, or jerky movements
Cerebellar function • Coordination and fine motor skill •
Accuracy of movement
•
Finger-to-finger test with personʼs eyes open
• •
•
Consistent past pointing may indicate cerebellar impairment
Heel-to-shin with person supine
•
Thursday, December 15, 2011
Movements should be rapid, smooth, and accurate
Should move heel from knee up and down the shin in a straight line, without irregular deviations to the side
Finger-to-nose test. A. Normal: Smooth trajectory throughout movement. B. Cerebellar hemisphere dysfunction: Tremor increases in amplitude as finger approaches target. C. Parkinsonian: Tremor may be present at initiation of movement, but smoothes out as finger approaches target. D. Essential tremor: Low-amplitude fast tremor throughout trajectory, may worsen as finger approaches target.
Thursday, December 15, 2011
Cerebellar function • Stance and gait • Gait • Tamdem walk • Rombergʼs test Thursday, December 15, 2011
Consequence of Neurologic Exam •
Mental status
• • • • • • • • Thursday, December 15, 2011
Consciousness: Level of consciousness, orientation Higher cortical function
Cranial nerves Motor system Reflex Sensory Coordination Gait and balance
Special test
Surat Tanprawate, MD, MSc(Lond.), FRCP(T) CertHE(Hist Med) Neurology staff, Division of Neurology, CMU The Northern Neuroscience Center, CMU
Downloadable at www.openneurons.com
Thank You for Your Kind Attention Thursday, December 15, 2011