Physical Assessment 2. Class 2

Transcription

1 Physical Assessment 2 Class 2

2 Goals Class 2: Goals: Understand the significance of common neurological symptoms Analyze common eye and ear conditions Learn the protocol of cranial nerves I, II, III, IV and VI examinations Objectives: At the end of the class, the student will be able to: Define and distinguish various types of headaches and their relative importance Recognize eye conditions, which require referrals Perform cranial nerve examinations of I, II, III, IV and VI

3 Common Neurological Symptoms Related to the Head Headache Cranial Nerve Pathology Spinal Nerve pain

4 Headaches Primary: Headaches without known causality Secondary: Related to another pathology or underlying physiological condition

5 Headaches: General Causes In your history or work up consider the following causes: 1. Trauma (soft tissue swelling, fracture,etc.) 2. Tumor or space occupying lesion (blood) 3. Infection (virus, bacterial, mold/yeast) 4. Metabolic (diabetes, miasthenia gravis) 5. Inflammation (sinustis, soft tissue swelling) Combine the above considerations with a good history, good physical exam to come up with a reasonable working diagnosis

6 Primary Headaches: TensionType Location: varied Quality: Pressing/tightening pain, mild to moderate intensity Onset: gradual Duration: Minutes to days Exacerbated with prolonged muscle tension, such as driving or typing Alleviated with massage/manual therapies, relaxation Sometimes photophobia or phonophobia, no nausea

7 Primary Headaches: MigraineType Location:Unilateral in about 70%, bifrontal or global in about 30% Quality: Throbbing/aching, varied severity Onset: Often rapid, 1-2 hours Duration: 4-72 hours Associated with nausea, vomiting, photophobia, phonophobia, visual auras (flickering zigzagging lines), motor auras affecting hands or arms, sensory auras (numbness or tingling preceeding headache) Exacerbated by possibly allergic foods, caffeine, ETOH, tension, yeasts, premenstrual timing, bright lights and noise aggravate Alleviated by quiet, dark room, sleep, pressure on involved artery

8 Primary Headaches: ClusterType Location: Unilateral, near eye Quality: Deep, continuous, severe Onset: Abrupt, peaks within minutes Duration: Up to3 Hours Associated with lacrimation, rhinorrhea, miosis, ptosis, eyelid edema, conjunctival infection Possibly related to ETOH sensitivity

9 Secondary Headaches: Analgesic or withdrawl Rebound Location: Previous Headache pattern Quality, Onset, Duration: Variable and related to previous headache type Fever, CO, hypoxia, caffeine with drawl can all exacerbate this headache type

10 Secondary Headaches: Occipital Neuralgia Pain along distribution of Occipital Nerve

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12 Secondary Headaches: Eye Disorder Related Location: Around eye/orbit and possibly occiput Q: Steady, aching, dull Onset: Gradual Duration: Variable Exacerbated by Prolonged eye use, esp. close reading Alleviated by eye rest Eye may feel sandy, gritty, and have redness of the conjunctiva

13 Secondary Headaches: Acute glaucoma Location: Around eye/orbit, unilateral Quality: Steady, aching, often severe Onset: Often rapid Duration: Variable Exacerbated by eye dilation often Associated with diminished vision, nausea, vomiting Refer for opthalmic eval.

14 Secondary Headache: Sinusitis Location: near frontal or maxillary sinus Quality: ache or throbbing, variable severity, Rule out migraine Onset: Variable Duration: Often several hours, over several days or more prolonged Exacerbated by coughing, sneezing, jarring head Associated with local tenderness, nasal congestion and discharge, allergic symptoms, fever Alleviated with analgesics, antibiotics, decongestants, nasal flush

15 Secondary Headache: Meningitis Location: Generalized Quality: Steady or throbbing, very severe Onset: Often rapid Duration: Variable, often days Associated with fever, neck stiffness Refer for spinal tap/cbc

16 Secondary Headache: Giant Cell (temporal) Arteritis Location: Temporal or occipital artery, or other involved artery, age-related (older) Quality: Throbbing, generalized, persistent, often severe Onset: Gradual or rapid Duration: Variable Associated with fever, weight loss, scapl tenderness, visual loss, polumyalgia rheumatica Exacerbated by Mov t of neck and shoulders

17 Secondary Headache: Posttraumatic Headache Location: May be localized to injured area, but sometimes referred Quality: Generalized, dull, aching, constant Onset: 1-2 days post injury Duration: Weeks, months, even years Associated with poor concentration, memory alterations, vertigo, irritability (often minor brain injury/concussion) Exacerbated: with mental exertion, straiing, ETOH, emotional excitement Alleviated with rest

18 Secondary Headache: Subdural or subarachnoid hematoma Location: Generalized Quality: Very severe, worst of my life, like a baseball bat hit my head Onset: Often abrupt, severe Duration: variable, sometimes days Associated with nausea, vomiting, possible loss of consciousness, neck pain Refer for immediate CT

19 Secondary Headache: trigeminal Neuralgia Location: trigeminal distribution, most commonly divisions 2 & 3> 1 Quality: Shock-like, stabbing, burning, severe Onset: Abrupt, paroxysmal Duration: Months Associated with exhaustion from recurrent pain TX: Steroid injections, acupuncture, surgery, medication

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22 Secondary Headaches: Other considerations Referred head pain from Teeth, Jaw, Neck Dehydration Low blood sugar or glycemic dysregulation Food or environmental allergies Often Helpful to get CBC, Chem-14, ESR, or other blood tests as helpful and inexpensive screening tools

23 Fundoscopic Evaluation

24 Otoscopic Evaluation

25 Cranial Nerves! Know the Cranial Nerve spreadsheet top to bottom, inside out you will see heavy testing over this information. It should become second nature to you, both the names of the nerves and their general function. The more normal nerves you see the more apt you will become in recognizing abnormal presentations

26 Common Causes of Cranial Metabolic: Diabetes Nerve Pathology Trauma: tissue swelling on nerve/nuclei, boney damage to nerve, blood on nerve or nucei Infection: Viral infection possible in many nerves Stroke/Infarct: Altered blood supply to nerve Congenital damage/defect

27 Cranial Nerve I: Olfactory Nerve

28 CN I - OLFACTORY ORIGIN: Cerebral hemisphere INNERVATION: Nasal mucous membranes. FUNCTION: Sense of smell DYSFUNCTION: Anosmia CLINICAL EVALUATION* *Note: Not routinely performed! Ask the patient if they can smell OK! Use aromatic substances, i.e. coffee, lemon, garlic, vanilla,etc. Test each nostril separately. 10/3/2008 Dr. Joel Cone 28

29 CN I

30 Note: Worry about an undiagnosed skull fracture in a patient post skull trauma or skull (cranio-facial) surgery that notes chronic sinus drip. It may be CerebroSpinal Fluid!

31 Cranial Nerve II: Optic Nerve Vision

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33 CLINICAL EVALUATION CN II - OPTIC VISUAL ACUITY: look at far object for distant vision, newspaper or fingers for near vision. VISUAL FIELDS: Confrontation. SPECIFIC DYSFUNCTIONS Blurred vision or complete blindness. Ipsilateral (sameside) vision loss - Optic atrophy, retinal/optic nerve lesions, trauma. Visual loss (one or both eyes) often at Optic chiasm or occipital lobe lesions(stroke, tumor, neuropathy) Cortical blindness - Lesion of occipital cortex bilaterally, pupil reflexes intact. Papilledema - Optic nerve tumor, venous obstruction, chronic increased ICP. Optic atrophy MS*, optic neuritis, increased ICP* Scotomas- (Abnormal blind spots on visual fields) - optic neuritis or atrophy. Hemianopia - (loss of half of visual field in one or both eyes) - Lesions of optic chiasm, tracts, or radiations. *MS-multiple sclerosis, ICP-intra cranial pressure 10/3/2008 Dr. Joel Cone 33

34 6 extrinsic eye muscles for eye movement

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36 Clinical Visual defects are Fairly common. Consider glaucoma, cataract, vitreal or retinal detachment, tumor, transient ischemic attacks, stroke, aneurysm, etc. 10/3/2008 Dr. Joel Cone 36

37 Easy eye muscle memory tool LR6 (lateral rectus controlled by CN VI) SO4 (superior oblique controlled by CN IV) AO3 (all other eye muscles controlled by CN )III

38 CN III - OCULOMOTOR ORIGIN: Midbrain INNERVATION:* EOM's; eyelid; ciliary; and sphincter of iris. FUNCTION: Eye movement inward (medially), upward, downward, and outward; pupil constriction, shape and equality; elevates upper eyelidccommodation reflex. DYSFUNCTION:Unable to look up, down, or medial (dysconjugate gaze); ptosis, pupil dilatation - bilateral or ipsilateral, loss of accommodation reflex. CLINICAL EVALUATION Observe for eye opening and symmetry (does the lid lag or open halfway?) Direct light response - brisk, sluggish, or non-reactive (do the pupils constrict?) Pupil size and shape (normal or abnormal?) Accommodation (do eyes focus in on finger as it moves toward the glabella?) *Extraocular movement (EOM's) NOTE: 4 th (Trochlear) supplies sup.oblq. Note: 6 th (Abducens) supplies lateral rectus muscle SO4 LR6 AO 3 10/3/2008 Dr. Joel Cone 38

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40 CN IV- TROCHLEAR ORIGIN: Midbrain INNERVATION: Superior oblique muscle. FUNCTION: Down and inward movement of the eye. DYSFUNCTION: Loss of downward, inner movement of eye, dysconjugate gaze. CN VI- ABDUCENS ORIGIN: Pons INNERVATION: Lateral rectus muscle. FUNCTION: Outward, lateral movement of eye. DYSFUNCTION: Loss of lateral eye movement, dysconjugate gaze (cross-eyed). Extraocular movements (EOM's) CN IV (Trochlear) and CN VI tested with CN III (Oculomotor) 10/3/2008 Dr. Joel Cone 40

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42 Clinical Movement disorders in the eye can be muscular or nerve related. Very commonly sudden onset disorders in CN III, IV, or VI may be related to metabolic nerve damage, such as seen in diabetes. They may also relate to stroke, TIA, etc. 10/3/2008 Dr. Joel Cone 42

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45 CN V - TRIGEMINAL ORIGIN: Pons. The sensory nucleus extends from the pons to the midbrain, and also to the medulla and spinal cord. INNERVATION: Three branches of CN V: Ophthalmic, maxillary, & mandibular. Motor innervation to masseter & temporal muscles. Sensory innervation to skin & mucous membranes in head; teeth, tongue, external auditory canal, and cornea. FUNCTION: Sensation of pain, touch, hot, & cold; motor movement of masseter & temporal muscles. Nerve Root Patterns DYSFUNCTION: Loss of sensation - if affecting all three branches, indicative of peripheral injury. Brainstem or upper cervical cord injury may result in loss of sensation to one or more branches of the trigeminal nerve. - Loss of corneal reflex. - Paresthesia and/or severe pain Indicative of nerve compression or irritation (Trigeminal neuralgia) - Deviation of jaw, loss of sensation. Brain Stem lesion = 10/3/2008 Inability to bite down and chew, inability Dr. Joel Cone to Onion skin sensory deficit 45 close jaw.

46 CN V - TRIGEMINAL SENSATION: Test with patients eye closed. Evaluate pain, temperature, & light touch to jaw, cheeks, and forehead. Observe response and symmetry. MOTOR: Open jaw, check for deviation. Have patient bite down, palpate masseter and temporal muscles. Move jaw laterally against resistance to evaluate weakness or paralysis. CLINICAL EVALUATION CORNEAL REFLEX: (SENSORY BY TRIGEMINAL) Cotton wisp across cornea, observe for blink (MOTOR function of CN III) JAW JERK: Tap lower jaw with mouth open - check for slight elevation of mandible 10/3/2008 Dr. Joel Cone 46

47 Clinical Trigeminal Neuralgia (tic Doularoux) is an excruciatingly painful process. May patients describe it as the most painful thing they have ever encountered. Treatments include conservative therapies (acupuncture, chiropractic or osteopathic manipulation, nutrition and herbs, EMS and ultrasound), injection nerve block, cryo or thermal ablation, medication (neurontin) 10/3/2008 Dr. Joel Cone 47

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49 Cranial Neve I-VI exam: keeping it simple CN I-VI eval Ocular movements (which mov t is which nerve? Light Response (CN II is to see light, CN III reacts to it with pupillary constriction) Pupil size and shape normal = CN III Accomodation (CN III: do eye follow finger and pupils constrict?) Touch face, light touch or pinwheel(cn V) Corneal reflex (V to sense, III to respond with a blink) Jaw jerk (CN V-slight=normal, big bilateral upper motor neuron disorder) Clench teeth, masseter and temoralis muscles: (CN V)

50 Review Understand functions of the CN I-VI Be able to perform and explain slide 49: CN exam: keeping it simple Be able to write a short answer question on how to test for CN I-VI function Be able to identify common Headache causes and types for a written test