CNS EXAMINATION PDF
☤Perform a neurological examination. ☤Higher function. ☤Cranial nerves. ☤ Motor system. ☤Sensory system. ☤Interpret neurological examination. 7 categories of the neurological exam. • Mental status. • Cranial nerves. • Motor system. • Reflexes. • Sensory system. • Coordination. • Station and gait. The neurological exam should be incorporated into the rest of your physical In practice, the neurological exam is tailored to the patient's.
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The goal of the examination is to identify the overall condition of the patient, to Performing the neurological examination in a standard fashion and presenting. 1 instruktsiya.info NEUROLOGICAL EXAMINATION Professor Shumway-Cook A and Neurological examination PDF manual. NEUROLOGIC EXAM DETAILS FROM NEURO EXAM VIDEO B. If the patient is sitting too far back on the exam table, the examiner might ask patient.
Specific muscles are innervated through a single cord segment because the spinal cord is arranged through separate reflex arcs. Absence of sensory abnormalities are seen when the lesion is entirely anterior horn. Lesions of the extrapyramidal system will produce bradykinesia with slowness of movement, tremor, shuffling walking with small steps, slow movements, resting tremor, and slowing of mentation as well as initiating movements.
Posterior column syndromes involve ataxia, dysmetria with impossibility of coordinated smooth movements, overshooting the mark and increase in symptoms after elimination of vision. Syndromes of cerebellar abnormalities involve decomposition of movement, inability to perform movements smoothly, hypertonia, excessive rebound, and intention tremor.
Identify 3 common neurological disorders tested during a neurological evaluation. Identify the major components of the motor exam. Describe the two sensory modalities tested using the sensory exam.
Chapter 10 - Motor system examination
Describe three common tests used to assess cerebellar dysfunction. Introduction The purpose of this course is to summarize the main parts of the neurological exam. Familiarity with this material will allow you to diagnose common neurological disorders, identify neurological emergencies and make referrals to appropriate specialists.
Any health professional faced with the task of assessing a person with an emergent, acute or even long-standing neurological deficit knows the importance of a quick and reliable neurological exam. Your knowledge of neurological evaluation techniques will allow you to gather accurate information about your client's medical condition and help you to create an accurate plan of care.
Once you are familiar with the neurological exam, you should be able to complete the exam in 10 to 15 minutes. Additionally you will learn some of the tests that are used to identify certain types of common neurological dysfunctions. The course will cover the following parts of the neurological evaluation: This will help to create a baseline as well as providing you with valuable information about the course and characteristics of the present illness.
The following information is gathered during the patient history portion of the neurological exam: The personal history should include a brief personal profile and description of the patient. A brief family history should be included, the source of the information indicated and the mental status of the patient noted.
Included in this section are the following items: A description of the current problem or "chief complaint" and the reason the patient is seeking medical care should be noted. Ask for an explanation of current signs and symptoms including any physical or psychological changes. Ask about the presence of dizziness, headaches, visual disturbances, speech or motor control problems.
Inquire about the onset and duration of symptoms and remember that in an emergent neurological event the progression of symptoms may help to identify the part of the brain that has been affected. The following items are included in this section www. Analysis of the "main symptom" including location, quality, severity, onset, duration, frequency and factors that aggravate or alleviate the condition.
Past medical history. Ask about the person's past medical history, previous illnesses and psychological history. Include educational background and any recent change in personality or behavior. Prior level of function is a critical piece of information that helps to establish the extent of the current neurological damage and helps you to differentiate between longstanding and emergent signs and symptoms.
Ask about the person's level of daily activities and use of assistive devices prior to the onset of the current medical problem. Medication review. Ask the patient for a list of over-the-counter and prescription medications as well as use of recreational drugs and alcohol. Review of other major systems.
Ask the patient about any problems with the other major systems of the body including heart, lungs and abdomen. The Physical Exam The physical exam includes inspection of the skin and neck, carotid and heart sounds, blood pressure, heart rate and respiratory rate. The following items are inspected in this section: If the patient demonstrates cognitive functioning that is grossly intact including level of consciousness, alertness, speech, memory and judgement, there is no need to do a more formal cognitive assessment.
If it appears that any of the cognitive functions are impaired it will be necessary to do a more detailed cognitive assessment. The following items are included in the cognitive assessment: There are many acceptable methods to determine level of consciousness including the Glascow coma Scale, the Mini-Mental State or by categorizing the level of consciousness using descriptive cognitive scales.
Glascow Coma Scale A coma is defined by Jennett and Teasdale as "not obeying commands, not uttering words and not opening the eyes". The Glascow Coma table 1 scale was first developed in as a way to assess and monitor levels of consciousness. The Glascow Coma scale may be used in conjunction with the Glascow Outcome scale table 2 to determine level of recovery.
Glascow Outcome Scale Vegetative state No cerebral cortical function that can be judged by behavior Severe disability Conscious but dependent Moderate disability Independent but disabled Good recovery Able to participate in normal social life and able to return to work Table 3: Glascow Coma Scale Scores vs.
Stupor - the person appears to be in a deep sleep but can be aroused by noxious or vigorous stimuli. Coma - eyes closed, no directed motor or verbal activity and unarousable. Orientation is generally determined by asking the patient to answer a few common questions such as the name, place and time.
Other questions might include the year, date, day or the name of the president or vice president. Time is often the first part of orientation that is affected. The inability to remember one's name may be evidence of a psychiatric condition.
Speech and language. A detailed assessment of speech and language function is the job of a specialist.
Why is a neurological examination performed?
During the initial neurological assessment, however you will be trying to establish the presence of a speech disorder that did not exist prior to the onset of the current medical problem. During this gross assessment, it is most common to look for the presence of aphasia, a problem with the understanding of speech or the inability to communicate via speech.
Additionally, it is important to note the quality, clarity and fluency of speech. The following items are contained within a speech and language assessment: Rate and rhythm - look for changes in the rate and rhythm of speech.
Prosody - aprosodia occurs due to a lesion in the right parietal lobe - the part of the brain that is involved with the tone and musicality of speech.
A patient with a lesion to this part of the brain will have flat intonation and a loss of pitch. There will also be a change in the accentuation and stress of words and syllables. Aphasia can affect modalities other than speaking such as writing, gesturing and other non-verbal aspects of communication.
For the purpose of a basic neurological exam it is sufficient to classify the aphasias as receptive, conductive or expressive.
Speech is often clear and fluent and language is normal in rate, rhythm and melody but there may be errors in words as well as the presence of added syllables.
Language may be excessive and convey little meaning. Comprehension is usually severely affected. Conductive aphasia. Speech is clear, but the patient is unable to repeat words. There is the ability to follow commands because comprehension is usually preserved.
Naming and repeating is severely impaired. Reading aloud is impaired but reading silently is conserved. Speech is fluent but with many incorrect words or sounds substituted for correct words. Expressive Broca's aphasia. Comprehension is usually well preserved but speech is unclear and non-fluent. Patients tend to use only key words and omit many nouns and verbs. Neurological damage may extend to the frontal lobe motor control areas adjoining Broca's area.
The portion of the exam that tests memory skills is usually divided into three parts immediate, recent and past memory.
Why is a neurological examination performed?
Immediate - ask the patient to recall a few objects over the span of 3 to 5 minutes. Recent - ask the patient to recall events within the last several hours to several days. Common questions might include, "What did you have for breakfast? Past - ask about events from childhood or long ago events. Fund of information.
Ask about current events, name of the president, geography, etc. Insight and judgement. Ask about the patient's understanding and awareness of the current illness.
Abstract thought. Ask the patient to compare and contrast two objects such as a car and a bus or a cucumber and an apple. Ask the patient to interpret a complex concept or political event. Ask the patient to do a calculation such as counting backwards from by increments of 7 or count upwards by threes.
Ask how many dimes are in a dollar or how many weeks in two years. The Cranial Nerves Assessment of the cranial nerves provides information about the function of the nerves in the head and neck region. With practice this part of the neurological exam can be completed in just a few minutes.
The cranial nerves are arranged along the brainstem in descending order from 12 to 1. CN I is located just above the olfactory epithelium on the inferior surface of the frontal lobe. CN II is located on the inferior surface of the cerebrum behind the eyes. Cranial nerves 12 - 9 are located in the medulla oblongata, the part of the brainstem contiguous with the spinal cord.
Cranial nerves 8 - 5 are located along the pons, the next portion of the brainstem. Cranial nerves 4 and 3 are located in the area of the midbrain, the uppermost portion of the brainstem. CN I - The olfactory nerve. The olfactory nerve is a sensory nerve responsible for smell.
Assessment of CNI is often omitted unless it is suspected that there is damage to the inferior frontal lobe - the area where the olfactory nerve is located. First make sure the nostrils are patent.
CN I is usually tested by holding coffee, rubbing alcohol or some other pungent or aromatic substance under the nose of the patient. Compare one side to the other. CN II - The optic nerve. The optic nerve is a sensory nerve responsible for vision. Always test this cranial nerve because it will give you information about visual acuity and visual fields deficits. Test visual acuity, visual fields and fundi.
Visual Acuity. Use the eye chart from your toolkit and test the patient's corrected vision in good light. Have the patient stand 20 feet from the eye chart then read the smallest line possible. Test both eyes. Compare the results of this test to the patient's prior level of function. Visual fields. It is important to test for the presence of visual field deficits if you suspect a disorder that is located in front of the optic chiasm.
The visual fields are tested by positioning your finger or a pencil beside the patient's temple in the area of the peripheral vision. Slowly bring the object forward and ask the patient to say when the object becomes visible.
Move the pencil or finger up, down, right, left and www. Keep your movements small and slow - it is easier for the eye to detect motion and will make the test less sensitive to visual field defects.
Neurological Examination for Children
Common visual field deficits include: Look closely at each eye and check for symmetry, clarity, color, contour, retinal abnormalities and the condition of the blood vessels in the eye. The oculomotor, trochlear and abducens are motor nerves responsible for control of all eye movements and innervation of all the extraocular eye muscles.
CN III controls most of the extraocular eye muscles, eye opening and pupillary constriction. CN IV controls downward and inward eye movements. CN VI controls lateral eye movements. These cranial nerves are responsible for motor control of the eye muscles, eyelids and the pupils. They are tested in a group because they work together to control eye movement. Check the eyelids for drooping and symmetry. An eyelid drooping over the pupil CN III may indicate the presence of myasthenia gravis or 3rd cranial nerve palsy.
Hold your finger in front of the patient and ask her to follow your finger as you move it through the 6 cardinal fields. The cardinal fields are: Check pupil function for response to light.
With the room darkened shine a penlight into one eye and look for pupil constriction - this is called a direct response. The opposite pupil should also constrict - this is known as a consensual response. Next ask the patient to look at a distant object and then at your finger which is held about 4 inches in front of the patient's nose.
The pupils should constrict and the eyes converge when the eyes shift from the distant object to your finger. Dilated or constricted pupils may indicate neurological disease, glaucoma, drug abuse or reaction to certain medications. Finally check for the position of the eyes in primary gaze by having the patient look straight ahead, then shine a bright light into the pupils. The reflection of the light should be the same in each pupil.
A deviation suggests the presence of a strabismus - the inability to align the visual axes so they are directed at the same point. In addition to checking these functions remember to look for the presence of horizontal and vertical nystagmus. Have the patient hold a lateral gaze for 5 to 10 seconds. If a brainstem lesion is suspected, vertical nystagmus is often present and is almost always an indication of central nervous system damage as opposed to vestibular dysfunction.
The trigeminal nerve is a mixed motor and sensory nerve that innervates the muscles of mastication and sensation from the skin, muscles and joints in the face, mouth and teeth and lateral jaw movement. Both motor and sensory components should be assessed. The motor portion of the trigeminal nerve is tested by palpating the masseter muscles while the patient clenches the jaw and by testing the strength of the jaw while opening and closing the mouth.
If a weakness is present the jaw will deviate to the weak side. The sensory portion of the trigeminal nerve can be tested for temperature sensation using the metal surface of your tuning fork or using test tubes filled with warm and cold water. The corneal reflex should be tested in a patient with suspected brainstem or hemispheric lesions by having the patient look up and away from the examiner.
Approaching the eye from the side, lightly touch the cornea of one eye with a piece of cotton. Repeat in the other eye.
A symmetric blink reflex should be present. Absence of the blink reflex indicates a 5th or 7th cranial nerve lesion. The facial nerve is mixed motor and sensory. The motor portion innervates the muscles of facial expression, the lacrimal and salivary glands. The facial nerve can be tested by asking the patient to smile, wrinkle the forehead, puff out the cheeks and close the eyes tightly. Look for symmetry from side to side and differences between the upper two-thirds and the lower one-third of the face.
Weakness in the upper part of the face may indicate a central nervous system lesion while weakness in the lower one third may indicate a peripheral nervous system problem.
The vestibulocochlear nerve is sensory for hearing, balance and orientation in space. Cranial nerve VIII is responsible for two main functions - control of vestibular function and hearing. It is usually only tested in patients with symptoms of vertigo, imbalance or suspected lesions in the cerebellopontine angle or brainstem.
Hearing can be screened initially by asking whether of not the patient hears your questions. To test hearing acuity, cover one ear and test the other with a watch held close to the ear or by whispering. The vestibular portion of CN VIII is more complicated but should be tested if the patient reports symptoms of nausea, vertigo, anxiety or if there are signs of nystagmus, sweating, hypotension, vomiting, hypotension or postural deviations.
Use the caloric test in which the www. Irrigate the ear canal with cold water. If the vestibular pathways are intact and the patient is awake the caloric test will cause nausea, horizontal nystagmus and vertigo to the irrigated side. The glossopharyngeal and vagus nerves are both mixed motor and sensory nerves.
CN X innervates the smooth muscle of the heart, blood vessels, trachea, bronchi, esophagus, stomach and intestines. The motor portion innervates the muscles of the larynx, pharynx, palate and muscles of speech. The sensory portion innervates visceral sensation from the pharynx, larynx, thorax and abdomen. These cranial nerves supply motor control to the larynx as well as sensory control to the tongue.
Observe the position and symmetry of the palate at rest and as the patient pants of says "ahhh". Test the gag reflex by lightly touching the posterior wall of the pharynx on each side with a tongue blade - this is an indication of both glossopharygeal and vagus function. In addition, listen for a soft breathy voice and ask if the patient has had difficulty with swallowing.
Hoarse sounding speech may indicate vocal cord paralysis while nasal speech indicates paralysis of the palate. CN XI - The spinal accessory nerve. The spinal accessory nerve is a motor nerve that innervates the trapezius and sternocleidomastoid muscles. To test the trapezius muscles, ask the patient to shrug the shoulders upward while the examiner applies a downward pressure.
To test the sternocleidomastoid muscles, have the patient turn her head to the right while the examiner applies a gentle pressure in the opposite direction. During both of these tests look for symmetry of motion from side to side and palpate the muscles to look for atrophy, abnormal tone or fasciculations in the muscle. Also note the strength of the contractions. Slow, alternating motion may indicate the presence of a central nervous system lesion while atrophy and fasciculations may indicate the presence of a peripheral nervous system lesion.
The hypoglossal nerve is responsible for motor control of the intrinsic muscles of the tongue. Check the position of the tongue within the mouth then look for smoothness of movement and symmetry as the patient protrudes the tongue and moves it from side to side.
The Motor Exam www. Begin by checking the general appearance of the patient - preferably with the clothes removed. Inspect the muscles visually and by palpation and note the presence of muscle fasciculations, abnormalities in muscle bulk and tenderness. The term muscle tone refers to the force with which a muscle resists lengthening.
Tone is present because of two factors - the mechanical elasticity of the muscle fibers and a neural component called the stretch reflex. Both of these factors resist uncontrolled lengthening of the muscle and contribute to the natural tone of the muscle. Tone is assessed clinically by passively flexing and extending the patient's limbs and noting the resistance of the muscles. Look for the presence of hypotonicity, hypertonicity, rigidity or spasticity. When checking for tone, make sure the patient is fully relaxed then take hold of the wrist and shake it back and forth.
Raise the arm and drop it onto a soft surface. Grasp the ankle and shake it from side to side. Finally, with the patient in supine, raise the knee quickly and observe the movement of the ankle. Normally, when no abnormal tone is present, the foot will slide along the bed without lifting into the air. Muscle strength is usually assessed on a scale of with 0 being no movement and 5 full movement against strong resistance. The following muscle groups are typically tested: If neurological dysfunction is suspected it is more important to look for patterns of weakness and changes in tone rather than the strength of individual muscles.
Depending upon the findings a more detailed strength exam may be needed. The general patterns to be aware of are as follows: Proximal weakness - look for the presence of hip and shoulder musculature weakness commonly seen in muscular dystrophies. Distal weakness - look for the presence of weakness in the small muscles of the hands and feet commonly seen in peripheral neuropathies.
Abnormal movements. During the motor portion of the neurological screen the examiner should note the presence of any of the following abnormal movement patterns: Bradykinesia is a common symptom of Parkinson's disease. Athetosis - large amplitude uncontrolled movements. Athetosis occurs because of damage to the basal ganglia extrapyramidal system. It is common with certain types of cerebral palsy, head injury, stroke, long-term use of antipsychotic medications and other disorders that damage the basal structures of the brain.
Chorea and ballism - smaller amplitude abrupt, uncontrolled movements. Also due to damage to the extrapyramidal system. Tremors - small amplitude movements that may be present at rest or with movement. A wide range of neurological disorders may exhibit some type of tremor including cerebral stroke, cerebellar stroke, Parkinson's disease, basal ganglia disorders as well as various drug reactions.
The stretch or deep tendon reflexes 2. The superficial or cutaneous reflexes Stretch reflexes. The stretch reflex is a type of spinal reflex also referred to as the deep tendon or myotatic reflex.
Stretch reflexes trigger a contraction when the muscle is stretched or lengthened. Typically, the following stretch reflexes are tested with the patient in a seated or supine position: In a normal response there will be a downward flexing of the toes.
If the great toe lifts and the other toes fan upward, the Babinski is positive and may indicate the presence of upper motor neuron damage. If the Babinski reflex is positive, a more thorough motor exam should be done. Superficial reflexes. The superficial reflexes are also referred to as cutaneous reflexes and include the following: The abdominal reflex is tested by scratching the skin near the umbilicus in a diagonal manner. In a normal response the umbilicus will pull in the direction of the stimulation.
Loss of this reflex may indicate a central nervous system lesion or an injury to the nerves that supply the umbilical region T7 to L1. Cremasteric reflex. The cremasteric reflex is tested by stroking the skin along the inner thigh and looking for a lifting of the scrotum on the stimulated side.
Anal wink. The anal wink is tested by stroking the perianal area and looking for a contraction of the anal sphincter. Pharyngeal or gag reflex. Test the gag reflex by touching the posterior wall of the pharynx with a tongue blade - this is an indication of both glossopharygeal and vagus function. Gait Gait is the single most important part of the motor exam because it allows to examiner to assess muscle strength, coordination, balance and timing - all vital higher cortical functions. Gait is also a vital functional skill and gives the examiner an idea of the ability of the patient to perform a complex motor task.
Ask the patient to walk down a hallway. Observe for symmetry, rhythm and speed while walking. Look for limping, scissoring, staggering, weight bearing and foot clearance during the swing phase. Observe the person walking toe to heel and note any abnormalities with balance and coordination during this task. If the patient has difficulty with any of these tasks involving gait or balance a more thorough balance evaluation should be done by a physical therapist.
Note any of the following common gait disorders: Festinating gait - a possible sign of Parkinson's disease. Hemiplegic gait with one-sided weakness - a possible sign of cerebral stroke. Spastic gait - a possible sign of cerebral palsy. The Sensory Exam The sensory portion of the neurological exam is very useful if the patient is cooperative and alert and able to give accurate responses to your questions. If the patient is uncooperative or unreliable the sensory exam is often skipped.
In general keep the following principles in mind during the sensory portion of the exam: Begin by applying a light sensation to one side of the body, then compare to the other side. Gradually increase the intensity of the stimulation.
The exam should focus on the suspected lesion. For example if a central nervous system lesion is suspected the tests should be directed towards central nervous system sensory tests. Sensory testing is usually divided into two parts: Primary sensory modalities such as pain, light touch, temperature, vibration and joint position sense.
Cortical sensory modalities such as stereognosis, two-point discrimination, graphesthesia and double simultaneous stimulation. Primary sensory modalities. The purpose of this part of the neurological exam is to test the sensory pathways that ascend via the spinal cord from the periphery to the sensory processing centers of the brain.
The following sensory modalities are commonly tested: The patient should be able to differentiate between sharp and dull. Light touch - lightly touch an area of the skin with your finger or a small piece of cotton. The patient should be able to identify the location of the touch. Vibration - place the stem of the tuning fork on the bony prominence of the ankle, shin, wrist, elbow, shoulder and sternum.
The patient should be able to name the location of the vibration. Loss of vibration sense suggests the presence of a peripheral neuropathy.
Joint position sense - hold the joint lightly in a neutral position between your two fingers. Raise or lower the digit or extremity and ask the patient to identify the direction of the movement. Cortical sensory modalities. Hence, in 3rd cranial nerve palsies and Homer syndrome, ptosis may result Figure 4. The eyelids are closed by the orbicularis oculi muscle, which is supplied by the facial 7th cranial nerve. In 7th nerve palsy, there is lagophthalmos an inability to close the eye.
Figure 3. Testing of the 9 cardinal positions of the eyes Figure 4.
Examination of the eyelids: image A shows right-sided ptosis from Horner syndrome and image B shows left-sided ptosis from 3rd nerve palsy Nystagmus Nystagmus is rhythmical oscillations of the eyes. It may occur in the primary gaze or in horizontal or vertical gaze.
Nystagmus has many causes, including ocular, vestibular and cerebellar conditions. Pendular nystagmus has equal speed in both directions and is commonly seen in congenital nystagmus. Examination of the eyes in an unconscious patient Examination of the eyes is important in the evaluation of the unconscious patient; it includes examination of the pupils and fundoscopy.
Pupils Pupillary testing involves assessment of the pupil size and reaction to light. In an unconscious patient, normal size and normally reactive pupils may suggest a metabolic encephalopathy from kidney failure, liver failure or electrolyte abnormalities. A unilateral or bilateral dilated pupil can suggest 3rd nerve palsy due to herniation of the brain through the tentorium cerebelli. This is a surgical emergency.
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Or no sentence up to 3yrs. Causes -MR -Deafness -articulation defect -bilingolism-physiological. Slurred speech…………………… pyramidal lesion. Monotonus speech ……………. Staccato speech………………… cerebeller lesion 7. Difficult in children. Optic nerve.
Efferent……3rd cr. However in individuals with UMNL the jaw jerk reflex can be quite pronounced. In unilateral lesion…. In bilateral lesion…uvula is central but immobile. Spinal accessory N. Sternomastoid……ability to rotate head to healthy side. Hypoglossal N. Rapid flexion of the head is accompanied by brisk flexion of both knee Inability to extend the knee,when the thigh is flexed at the hip Facial nerve Ataxic gait……ataxic CP.
Scissoring gait in spastic CP. Not able to walk. Small muscle of LL…. Intercostal m.
Of abdomen…….Move it up and down at random! Patients are unable to perform tasks such as a salute, form interlocking fingers, comb hair, stick out tongue, or pucker as if to kiss. The cranial nerves are arranged along the brainstem in descending order from 12 to 1. Test position sense by moving the toe or finger up and down, held by its sides, and have the patient report its position with eyes closed.
A long list of genetic disorders has been described with a predominant neurologic presentation but many more of the common neurologic disorders run in families. The axons of the PNS travel to and from the periphery, connecting the organs of action e.
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