Neurologic Examination Benchmarks

Transcription

1 Neurlgic Examinatin Benchmarks Preparatin & psitining: A cmplete neurlgic exam can be dne fllwing the musculskeletal exam, r the neurlgic exam can be integrated int the exam f each regin f the bdy. Cranial nerves culd be examined at the time f the head and neck exam; strength culd be tested during the musculskeletal examinatin. Mst ambulatry patients will be seated fr the majrity f the exam. Hspitalized patients may be supine. On cmpletin f FCM, yu shuld be able t demnstrate each step in a cmprehensive neurlgic exam: Observe the level f cnsciusness Mental Status Observe speech and language Assess rientatin t persn, place, and time Assess shrt term memry Test visual acuity & visual fields fr each eye alne (CN II) Test pupillary reactin (CN II and III) Test eyelid pening (CN III) Test extra-cular mvements (CN III, IV, VI), bserving fr nystagmus (CN VIII) Cranial Nerves Test facial sensatin & muscles f masticatin (CN V) Test muscles f facial expressin (CN VII) Test hearing (CN VIII) Test palatal rise t phnatin (CN IX and X) Test sterncleidmastid & upper trapezius muscle strength (CN XI) Test tngue prtrusin (CN XII) Mtr Functin Reflexes Assess strength, bulk, and tne f: Upper extremity muscle grups: Shulder abductrs, arm flexrs & extensrs, wrist flexrs & extensrs, finger flexrs, finger abductrs Lwer extremity muscle grups: Hip flexrs, extensrs, abductrs & adductrs; knee flexrs & extensrs, ft drsiflexrs & plantar flexrs Prnatr drift Upper extremity: biceps, triceps, & brachiradialis Lwer extremity: patellar & Achilles

2 Plantar reflex Sensatin Rmberg test. Mdify yur chice f the fur sensry mdalities t match the patient s sensry cmplaints: pin prick, vibratin, jint psitin sense, r light tuch Finger-t-nse test Cerebellar Testing Heel-t-shin test Gait Let s explre each f these steps further Observe the level f cnsciusness Mental Status Observe speech and language Assess rientatin t persn, place, and time Assess shrt term memry Yur initial evaluatin f mental status will ccur as yu greet and establish rapprt with the patient. Mst ambulatry patients are alert and riented; decreased level f cnsciusness and cnfusin are much mre cmmn in the hspital, and mild cgnitive impairment is cmmn in the elderly. Mre frmal questining abut rientatin and recall is apprpriate n initial evaluatin f these patient grups. The Mini-Cg is a screening test fr shrt term memry lss assciated with cgnitive impairment. Give yur patient a list f three items, fr example: Apple-Penny- Ball. Ask him t repeat them immediately and remember them fr 5 minutes. Give the patient a piece f paper with a circle drawn n it. Instruct him t draw a clck, placing the numbers n the clck face, with the hands pinting t a certain time. Then ask him t recall the 3 items. Cmmn abnrmal findings t recgnize: Decreased level f cnsciusness. Levels f cnsciusness are defined as: Alert: awake, with a nrmal level f cnsciusness. Lethargic: sleepy and requires stimulatin t maintain an awake state. Stuprus: cannt be arused t a fully awake state. May respnd semi-purpsefully t stimulatin. Cmatse: n purpseful respnse t any type f stimulatin.

3 Three item recall and mini-cg Recall f 0 items indicates cgnitive impairment. Recall f 1-2 items with an abnrmal clck face indicates cgnitive impairment. Recall f 1-2 items with a nrmal clck face indicates n cgnitive impairment. Recall f all 3 items indicates n cgnitive impairment. Interpreting the Mini-Cg Abnrmalities f speech r language include: Aphasia: disrder f language that manifests as prblems with cmprehensin, fluency, naming, arithmetic and/r writing. Caused by strke and ther brain disrders invlving language areas f crtex. Dysphnia: disrder f vice prductin caused by abnrmal larynx r vcal crd functin. Dysarthria: disrder f articulatin caused by abnrmal mtr cntrl f the pharynx, palate, tngue, lips and/r face. Test visual acuity & visual fields fr each eye alne (CN II) Test pupillary reactin (CN II and III) Test eyelid pening (CN III) Test extra-cular mvements (CN III, IV, VI), bserving fr nystagmus (CN VIII) 2. Cranial Nerves Test facial sensatin & muscles f masticatin (CN V) Test muscles f facial expressin (CN VII) Test hearing (CN VIII) Test palatal rise t phnatin (CN IX and X) Test sterncleidmastid & upper trapezius muscle strength (CN XI) Test tngue prtrusins (CN XII) Visual field testing. Remember that ne eye shuld be cvered and ne eye tested at a time. The patient sits ~ 3 feet frm the examiner and stares at her nse. The examiner mves an bject r finger frm the back f the patient s head int each quadrant f the visual field, asking the patient t reprt when he can see it. Pupillary reactin. Observe direct and cnsensual reactin f each pupil. The parasympathetic nervus system cnstricts the pupil and arrives at the eye via CN III. The sympathetic nervus system dilates the pupil and arrives via branches frm the nerve plexus alng the internal cartid artery. Pupillary size is determined by the balance f these tw inputs.

4 Extracular mtin. The eye muscles are tested by asking the patient t lk in 6 directins. The muscle tested in each directin is shwn fr the left eye. Medial Inferir Oblique (III) Up Superir Rectus (III) Lateral Medial Rectus (III) Lateral Rectus (VI) Superir Oblique (IV) Dwn Inferir Rectus (III) Cmmn abnrmal findings t recgnize: Aniscria. T determine the cause f unequal pupils, cmpare the degree f asymmetry in light and dark. If the degree f asymmetry is: The same in light and dark: The patient has physilgic aniscria, a nrmal variant in 20% f the ppulatin. Greatest in light: The patient has a parasympathetic prblem in the larger pupil. Lk fr ther signs f CNIII dysfunctin, such as ptsis r dyscnjugate gaze. Greatest in dark: The patient has a sympathetic prblem in the smaller pupil. Lk fr ther signs f Hrner syndrme, such as decreased facial sweating and ptsis. Facial weakness. A central r peripheral lesin f the 7 th cranial nerve will cause unilateral facial nerve palsy. Central and peripheral 7 th nerve lesins can be differentiated by hw much f the face is invlved. Central facial nerve palsy affects nly the lwer face, as the mtr neurns innervating the frehead receive input frm bth sides f the brain. Peripheral facial nerve palsy affects the entire face. Tngue weakness. Each geniglssus muscle pushes the tngue ut and t the ppsite side, s the tngue deviates t the side f weakness. Unilateral atrphy and twitching are als signs f weakness. 3. Mtr Functin Assess strength, bulk, and tne f: Upper extremity muscle grups: Shulder abductrs, arm flexrs & extensrs, wrist flexrs & extensrs, finger flexrs, finger abductrs Lwer extremity muscle grups: Hip flexrs, extensrs, abductrs & adductrs; knee flexrs & extensrs, ft drsiflexrs & plantar flexrs Prnatr drift

5 Islate the muscle yu are testing. Fix the limb abve the jint that it mves with ne hand. If yu are testing the biceps muscle, which flexes the arm at the elbw, fix the arm abve the elbw with ne hand while yur ther hand assesses strength. Exceptins are deltids, which are usually tested simultaneusly t avid tipping the patient, and the intrinsic muscles f the hand. Test triceps strength with the arm flexed 90 degrees at the elbw Grading strength 0 = n mvement 1 = flicker f mvement r slight twitch 2 = mves with gravity eliminated 3 = mves against gravity but nt against resistance 4 = mves against resistance but less than full pwer 5 = nrmal strength r pwer Cmmn abnrmal findings: Weakness can be a finding f central r peripheral mtr neurn disease r disrders f the neurmuscular junctin r muscle. Atrphy describes muscles that are wasted. Muscle bulk varies substantially acrss patients cmpare ne side t the ther. Atrphy suggests disuse f the muscle r lwer mtr neurn disease. Increased muscle tne can be caused by central nervus system disease (spasticity) r extrapyramidal disrders such as Parkinsn s disease (rigidity).

6 Upper extremity: biceps, triceps, & brachiradialis 4. Reflexes Lwer extremity: patellar & Achilles Plantar reflex Deep tendn reflexes are cmpared side-t-side, and are graded n a 0-4 scale: 0 = absent 1 = present but less than nrmal 2 = average 3 = increased 4 = clnus Absent r exaggerated reflexes are smetimes seen in nrmal peple. If the reflexes are symmetric and there are n ther findings f nervus system disease, n further evaluatin is needed. Brachiradialis reflex: Elicit this reflex by tapping yur fingers placed n the lateral arm, midway between the wrist and elbw. Lk fr cntractin f the brachiradialis in the lateral arm arund the elbw. Plantar (Babinski) reflex: Begin with a gentle stimulus (such as a thumbnail) drawn frm the heel alng the lateral sle and ver the metatarsal heads. If there is n respnse t gentle pressure yu can use firmer pressure. Nrmal in patients ver the age f 1 is dwnward mvement f the tes. Augmentatin maneuvers: If yu can t elicit a reflex, repeat as yur patient perfrms these maneuvers: Fr upper extremity reflexes: Clenches the jaw and cunts t 20 Fr patellar reflex: Hks the fingers f the right and left hands firmly tgether and pulls. Achilles reflex: Presses dwn lightly n yur hand, as if stepping n the gas Cmmn abnrmal findings: Absent r reduced reflexes. Peripheral nervus system disease causes absent r decreased reflexes, but nrmal peple and thse with sensry lss can demnstrate similar findings. Assciated weakness, atrphy, r fasciculatins all suggest lwer mtr neurn disease as the cause.

7 Exaggerated reflexes. Upper mtr neurn disease causes exaggerated reflexes, which can again be seen in nrmal peple. Assciated weakness, spasticity, r an abnrmal plantar reflex all suggest upper mtr neurn disease as the cause. Abnrmal plantar reflex (als called the Babinski sign): The abnrmal finding, which indicates upper mtr neurn disease, is upward mvement f the big te. 5. Sensatin Rmberg test Mdify yur chice f the fur sensry mdalities t match the patient s sensry cmplaints: pin prick, vibratin, jint psitin sense, r light tuch Sensry testing: Clues t lcalizatin in the brain r brainstem include sensry lss in large parts f ne side f the bdy that can t be explained by a single nerve r dermatme. Light tuch and pinprick are gd mdalities t test lking fr symmetry frm side t side. Clues t lcalizatin in the spinal crd include a sensry level n the trunk and asymmetric findings f vibratin/prpriceptin lss n ne leg with pinprick lss n the ther. Light tuch, pinprick, vibratin and prpriceptin are gd mdalities t test in the legs. Light tuch and pin are gd mdalities t find a sensry level n the trunk. A cape distributin is a rare presentatin in peple with central crd syndrme. Clues t lcalizatin in the peripheral nerve include a length-dependent sensry lss r sensry lss in small parts f ne side f the bdy that can be explained by a single nerve r dermatme. Light tuch, pinprick, vibratin and prpriceptin are gd mdalities t test fr a length-dependent prcess. Light tuch and pin are gd mdalities t find a fcal nerve prcess. Abnrmal findings: Rmberg test: A psitive Rmberg test is an inability t stay upright with the feet tgether after the eyes are clsed. It indicates a lss f lwer extremity psitin sense frm neurpathy r a psterir clumn prblem. Finger-t-nse test 6. Cerebellar Testing Heel-t-shin test Gait

8 Weakness, numbness, r visin prblems will interfere with yur patient s ability t perfrm these tests. Finger-t-nse test: Hlding yur hand in frnt f the patient, ask him t tuch his nse then yur finger, ging back and frth. Observe fr smthness and accuracy, cmparing the right and left sides. Unilateral incrdinatin indicates a prblem with the cerebellum n that side Heel-t-shin test: Ask the supine patient t place ne heel n the ppsite shin, and run the heel up and dwn the shin. Observe fr smthness and accuracy, cmparing the right and left sides. Gait: Ask the patient t walk acrss the rm, turn and walk back. Then ask him t walk heel t te in a straight line. Nrmal peple ver the age f 60 are ften unable t heel-t-te walk. Abnrmal findings: Recgnize these abnrmal gaits: Neurpathic Mypathic Ataxic Hemiplegic