NEUROLOGICAL EXAMINATION (1) Dr. Sema Saltık Ass. Prof of Child Neurology

Transcription

1 NEUROLOGICAL EXAMINATION (1) Dr. Sema Saltık Ass. Prof of Child Neurology

2 Neurological Examınatıon Consciousness level assessment, cooperation Disorders of speech and language Neck stiffness and evidences of meningeal irritation Cranial nerves Motor system Muscle power Muscle tone Sensation Reflexes Posture-gait disorders Cerebellar tests Higher cerebral function Movement disorders Other.

3 Consciousness is the quality or state of being aware of an external object or something within oneself. Consciousness is assessed by observing a patient's arousal and responsiveness. The abnormal state of consciousness ; Clouding of consciousness is a very mild form of altered mental status in which the patient has inattention and reduced wakefulness. Confusional state is a more profound deficit that includes disorientation, bewilderment, and difficulty following commands.

4 Abnormal state of consciousness Lethargy consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep. Obtundation is a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states. Stupor means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state. Coma is a state of unarousable unresponsiveness.

5 Glasgow Coma Scale Motor response Obeys commands 6 Localizing to pain 5 Withdraws to pain 4 Flexing to pain 3 Extending to pain 2 None 1 Verbal response Orientated 5 Confused 4 Words 3 Sounds 2 None 1 < 7 coma <5 deep coma Eye opening Spontaneous 4 To speech 3 To pain 2 None 1

6 Modified Pediatric Glasgow Coma Scale Verbal response Smiles, orients to sounds, follows objects, interacts 5 Cries but consolable, inappropriate interactions 4 Inconsistently inconsolable, moaning 3 Inconsolable, agitated 2 No verbal response 1

7 Language and speech disorders Anarthria-Dysarthria; Loss of the ability to vocalize words as a result of an injury to the part of the brain that is responsible for controlling the larynx or "voice box." (Cerebellar, Extrapyramidal, IX. X. Cranial nerve palsies) Aphasia, Dysphasia; a disorder caused by damage to the parts of the brain that control language. It can make it hard for you to read, write, and say what you mean to say. Broca s aphasia (Motor aphasia) (+right hemiparesis) Wernicke aphasia (Sensorieal aphasia)

8 Meningeal Irritation Evidences Neck stiffness Kerning s sign Brudzinski s sign

9 Meningeal Irritation Evidences

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11 I. Cranial Nerve- Olfactory Nerve Smell is tested in each nostril separately by placing stimuli under one nostril and occluding the opposing nostril. The stimuli used should be non-irritating and identifiable.

12 II. Cranial Nerve- Optic Nerve Visual acuity; is tested in each eye separately. The patient is asked to read progressively smaller lines on the near card or Snellen chart. Visual fields; are assessed by asking the patient to cover one eye while the examiner tests the opposite eye. The examiner wiggles the finger in each of the four quadrants and asks the patient to state when the finger is seen in the periphery. (Confrontation) Fundoscopy; Pupills; size, shape, equality, reaction to light, accommodation and convergence.

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14 Oculomotor (III), Trochlear (IV), Abducens (VI) Cranial Nerves Extraocular muscle movement Upward movement, looking out - superior rectus (Oculomotor nerve) Upward movement, looking in inferior oblique (Oculomotor nerve) Downward movement, looking out - inferior rectus (Oculomotor nerve) Medial movement medial rectus (Oculomotor nerve) Lateral movement lateral rectus ( Abducens nerve) Downward movement, looking in superior oblique (Trochlear nerve)

15 Oculomotor (III), Trochlear (IV), Abducens (VI) Cranial Nerves Diplopia; ask patient about diplopia and if present note the direction of maximum displacement of the images and determine the pair of muscles involved. Conjugate movements; is the ability of the eyes to act together to the horizontal or vertical direction Nystagmus; upset in the normal balance of eye control. Horizontal-vertikal Direction (e.g. Nystagmus to the right) Gaze direction where nystagmus is maximal (e.g. max. to lateral gaze) Ptosis;

16 V. Cranial Nerve-Trigeminal Nerve Motor fibres: innervate the muscles of mastication (Temporalis, masseter and pterygoid muscles) (Jaw jerk) Sensory fibres: subserves facial sensation Ophthalmic division Maxillary division Mandibular division CORNEAL REFLEX

17 VII. Cranial Nerve- Facial Nerve Motor fibres: supply the muscles of facial expression Visceral afferent fibres: convey sensations of taste from the anterior two-thirds of the tongue. Visceral efferent (parasympathetic) fibres: Salivation (sublingual, submaxillary, tears)

18 VIII. Cranial Nerve-Statoacustic Nerve Cochlear nerve: hearing Vestibular nerve: balance

19 IX. Glossopharyngeal nerve X. Vagus nerve These nerves are considered jointly since they are examinated together and their actions are seldom individually impaired. Swallowing difficulty, nasal regurgitation of fluids? Ask patient to open mouth and say aa, note any asymmetry of palatal movements. Note the patient s voice Taste in the posterior 1/3 of the tounge is impractical to test (IX) GAG REFLEX

20 XI. Cranial Nerve-Accessory nerve Sternocleidomastoid : ask the patient to rotate head against resistance. Compare power and muscle bulk on each side. Trapezius; ask the patient to shrug shoulders and to hold them in this position against resistance. Compare power on each side.

21 XII. Hypoglossal Nerve Motor nerve of the tongue Inspect tongue (atrophy, fasciculation) Ask the patient to protrude the tongue, note any difficulty or deviation. Tongue deviates towards side of the weakness.

22 Motor System Examination any asymmetry or deformity muscle wasting muscle hypertrophy muscle fasciculation power tone

23 Motor System Examination Upper Limbs Shoulder abduction- m.deltoideus Shoulder adduction- m. pectoralis major, latissimus dorsi Elbow flexion- m. biceps, brachioradialis Elbow extension- m. triceps Wrist Extension- ext.carpi radialis longus, ext. carpi ulnaris Finger extension Finger flexion Interosseous muscles

24 Motor System Examination Lower Limbs Hip flexion - Iliopsoas Hip extension- Glutei Hip abduction- Glutei and tensor fascia lata Hip adduction- Adductors Knee flexion- Hamstrings Knee extension- Quadriceps Plantar flexion- Gastrocnemius, tibialis posterior Plantar dorsiflexion- tibialis anterior,extensor hallucis longus,ext. Digitorum longus

25 Strength of Muscle Groups 0/5: no contraction 1/5: muscle flicker, but no movement 2/5: movement possible, but not against gravity (test the joint in its horizontal plane) 3/5: movement possible against gravity, but not against resistance by the examiner 4/5: movement possible against some resistance by the examiner 5/5: normal strength

26 Tone Ensure that the patient is relaxed, and assess tone by alternately flexing and extending the muscles. Normal tone İncrease in tone Spastisity Rigidity Decrease in tone

27 Posture and Gait Posture (decerebration, decortication, hemiplegic ) Gait Spastic Ataxia Cerebellar ataxia Sensory ataxia (Romberg s test) Steppage Parkinsonian Waddling gait - a duck-like walk

28 Sensory Exam I. SUPERFICIAL SENSATION Light touch Pain Temperature

29 Sensory Exam II. PROPRIOCEPTIVE SENSATION Position Sense Ask the patient close the eyes and report if their large toe is "up" or "down" when the examiner manually moves the patient's toe in the respective direction. Vibratory Sense A positive Romberg test suggests that the ataxia is sensory in nature, that is, depending on loss of proprioception.

30 Sensory exam III. CORTICAL SENSATION: (Parietal lobe) Stereognosia: Ask the patient to close their eyes and identify the object you place in their hand. Place a coin or pen in their hand. Two-point discrimination is the ability to discern that two nearby objects touching the skin are truly two distinct points, not one. Graphesthesia: Ask the patient to close their eyes and identify the number or letter you will write with the back of a pen on their palm. Touch localization (topognosis): ability to localize stimuli to parts of the body. Topagnosia is the absence of this ability.

31 Reflexes I- Deep Tendon Reflexes 0 No response, absent ± A reflex that is only elicited with reinforcement + Diminished ++ Normal +++ Hyperactive ++++ Hyperactive with clonus

32 Jaw Reflex N. trigeminus (V. CN) Pons The lower jaw is tapped at a downward angle just below the lips at the chin while the mouth is held slightly open. In response, the masseter muscles will jerk the mandible upwards. Normal response; this reflex is absent or very slight. Upper motor neuron lesions; the jaw jerk reflex can be quite pronounced

33 Biceps Reflex Normal response; forearm flexion Peripherial nerve: N. musculocutaneous Spinal segment: C5, C6 Palpate the biceps tendon

34 Triceps Reflex Normal response; forearm extension Peripherial nerve : N. radialis Spinal segment: C6, C7 Strike the patient s elbow a few inches above the olecranon process.

35 Brachioradial Reflex Normal response; flexion and slight supination of elbow, slight flexion of fingers Peripherial nerve : N. radialis Spinal segment: C5, C6 Strike the lower end of the radius

36 Patellar Reflex (Knee jerk) Normal response; sudden extension of the leg. Peripherial nerve : N. Femoralis Spinal segment: L2 - L4

37 Achille Rejlex (Ankle jerk) Normal response; plantar flexion Peripherial nerve : N. Tibialis Spinal segment: S1-S2 Externally rotate the leg Hold the foot in slight dorsiflexion Palpate the tendon of tibialis anterior (ensure the foot is relaxed) Tap the achille tendon

38 Superficial Neurological Reflexes Abdominal reflex Stroke or lightly scratch the skin towards the umblicus in each quadrant in turn. Look for abdominal muscle contraction and note if absent or impaired. Spinal segment: T7-T12 Cremasteric reflex Scratch inner thigh. Observe contraction of cremasteric muscle causing testicular elevation. Spinal segment: L1 Anal reflex Scratch on the skin beside the anus. Observe a reflex contraction of the anal sphincter. Spinal segment: S4, S5

39 Superficial Neurological Reflexes Plantar Reflex Stroke the lateral aspect of the sole and across the ball of the foot. Watch for the first movement of the big toe.

40 Clonus Series of involuntary, rhythmic, muscular contractions and relaxations Clonus is most commonly found at the ankle specifically with a dorsiflexion/plantarflexion movement (up and down). Clonus at the ankle is tested by rapidly flexing the foot into dorsiflexion (upward), inducing a stretch to the gastrocnemius muscle.

41 Cerebellar tests Dysmetria Finger-to-nose test Ankle-over-tibia test Dysdiadochokinesis Rapid pronation-supination Ataxia Assessment of gait Nystagmus Intention tremor Staccato speech

42 Movement disorders Chorea Athetosis Hemiballismus Dystonia Tremor Tic Myoclonus Fasciculation