Transcript 2 Neurological Exam

Physical Examination:
Neurological
Nose Exam
• Smell test
• CN I
Patient closes eyes
and plugs one nostril.
Hold an alcohol swab
a few inches away and
have them sniff.
Repeat with the other
nostril. Is the strength
of the smell the
same?
Eye Exam:
testing cranial nerves III, IV, and VI
• Instruct the patient to hold his head still and follow the
examiner’s finger with his eyes as the examiner
circumscribes a large "H" in front of the patient. Then
move the finger towards the patient’s nose. Weakness
in an eye muscle indicates cranial nerve damage.
• CN III also controls the pupillary reflex. Have the
patient look straight ahead, then shine a light into the
left eye once to see if the left pupil constricts. Remove
the light and shine it again at the left eye, but look at
the right eye to see if the right pupil constricts.
• Repeat this, shining the light twice in the right eye to
see if the right and left pupil constrict.
Look for Nystagmus
• Nystagmus is involuntary eye movement.
• http://en.wikipedia.org/wiki/Physiologic_nystagmus
• It is characterized by alternating smooth pursuit in one
direction and saccadic movement in the other
direction.
• Pathological nystagmus is the result of damage to one
or more components of the vestibular system, including
the semicircular canals, otoliths, and the
vestibulocerebellum.
• Many blind people have nystagmus, which is one
reason that some wear dark glasses.
Extraocular Movements:
CN III (except as listed)
CN VI
CN IV
Retinal Exam
• Have the patient stare at a the corner of the
room where the ceiling meets the wall.
• Approach the right eye from the right side of
the patient. Place one hand on their forehead
so you have depth perception and don’t run
into their face.
• Place the ophthalmoscope on your forehead
and look into the pupil. Examine the fundus
(interior of the eye) for abnormalities.
Normal Fundus
Diabetic Retinopathy
Diabetic Retinopathy
Hearing Loss
• Conductive hearing loss happens when there
is a problem conducting sound waves through
the outer ear, tympanic membrane (eardrum)
or middle ear (ossicles).
• Sensorineural hearing loss is a problem in the
vestibulocochlear nerve (Cranial nerve VIII),
the inner ear, or central processing centers of
the brain.
Weber Test
• Weber Test: only tests unilateral problems. A
tuning fork is touched to the middle of the
forehead:
– Sensorineural hearing loss: sound is heard louder
in the normal ear because the damage is to the
nerve, so bone conduction of the sound is
ineffective.
– Conductive hearing loss: sound is heard louder in
the problem ear (earwax, etc) because reflected
soundwaves cannot escape the ear canal, so they
penetrate deeper into the inner ear.
Rinne Test
• Performed by placing a vibrating tuning fork
on the mastoid process until sound is no
longer heard, the fork is then immediately
placed just outside the ear. Normally, the
sound is audible at the ear, indicating a
positive Rinne test.
• If they cannot hear the sound at the ear, it is a
negative Rinne test, and indicates
Sensorineural hearing loss
Middle Ear Exam
• Make sure a disposable specula is on the
otoscope!
• Approach the patient from the side.
• Grasp the pinna (external ear) and gently pull it
superiorly and posteriorly to straighten out the ear
canal.
• Place the specula of the otoscope into the ear first,
before looking into the otoscope. Otherwise, you might
drive the specula in too deep and hurt the patient.
• Then look into the otoscope. Examine the canal for
redness, look for perforation or scars on the tympanum
(ear drum).
Normal Ear
Inflamed Ear
Neurological Exam
Gait and Station
• Tandem gait
– walk a straight line while touching the heel of one foot to
the toe of the other with each step. Tests cerebellar
function.
• Hopping on one foot (not for feeble patients)
• Romberg
– Ask the patient to stand with their feet together (touching
each other). Then ask the patient to close their eyes.
Remain close in case the patient begins to sway or fall.
– With the eyes open, visual input helps to maintain stability.
Closing the eyes and having difficulty with the task
suggests a mild lesion in the vestibular system.
Cerebellar Function
• Finger to Nose
– Patient is asked to alternately touch their nose and the
examiner's finger as quickly as possible, while the examiner's
finger is held at the extreme of the patient's reach, and the
examiner's finger is occasionally moved
• Heel to Shin
– Touch the heel of one foot to the opposite knee and then to
drag their heel in a straight line all the way down the front of
their shin and back up again. In order to eliminate the effect of
gravity in moving the heel down the shin, this test should always
be done in the supine position.
• Rapid Alternating Movements
– Wiping one palm alternately with the palm and dorsum of the
other hand
Reflexes
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•
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Biceps (C5-6)
Triceps (C7)
Patellar (L4)
Ankle (S1)
Plantar
– Babinski sign
0: absent reflex
1+: trace
2+: normal
3+: brisk
4+: nonsustained clonus (i.e.,
repetitive vibratory
movements)
5+: sustained clonus
Deep tendon reflexes are normal if they are 1+, 2+, or 3+ unless they are
asymmetric or there is a dramatic difference between the arms and the legs.
http://www.neuroexam.com/content.php?p=2
http://meded.ucsd.edu/clinicalmed/neuro3.htm
Reflexes Exam
• The limbs should be in a relaxed and symmetric
position.
• The muscle group to be tested must be in a neutral
position (i.e. neither stretched nor contracted).
• Compare each reflex immediately with its contralateral
counterpart so that any asymmetries can be detected.
• If you cannot elicit a reflex, you can sometimes bring it
out by certain reinforcement procedures. For example,
have the forcefully contract a different muscle group
when the reflex is tested.
Biceps Reflex
• Have the patient’s elbow resting in your arm at a 90 degree
angle.
• Place your thumb over the antecubital fossa (inside of
elbow) of the patient.
• Ask the patient to flex their forearm (i.e. contract their
Biceps muscle) while you simultaneously palpate the fossa.
The Biceps tendon should become taut and thus readily
apparent.
• Place your thumb over the
tendon and tap the pointed
side of the reflex hammer onto
your thumb and observe the
reflex in their biceps.
Triceps Reflex
• Have the patient’s elbow resting in your arm at a
90 degree angle.
• Ask the patient to extend their forearm (i.e.
contract their Triceps muscle) while you
simultaneously palpate the tendon behind the
elbow.
• Place your thumb
over the tendon and
tap the pointed side
of the reflex hammer
onto your thumb and
observe the reflex in
their triceps.
Patellar Reflex
• Make sure the leg is
relaxed.
• Use the wide side of the
hammer.
• If no reaction, have patient
clasp fingers together and
pull while the test is
performed.
Achilles Tendon Reflex
• This is most easily done with the patient
seated, feet dangling over the edge of the
exam table.
•Use one hand to hold
the foot at a 90 degree
angle, and strike the
tendon with the wide
side of the hammer in
the other hand. Feel for
the foot plantarflexion.
Plantar Reflex
• Scrape an object across the sole of the foot
beginning from the heel, moving forward toward
the small toe, and then arcing medially toward
the big toe.
• The normal response is downward contraction of
the toes.
• The abnormal response,
called a positive Babinski's
sign, is characterized by a
dorsiflexed big toe and
fanning outward of the other
toes. This is normal in
children under 1 year of age,
but abnormal in adults.
Cranial Nerves
• Olfactory (I) smell
• Optic (II) Visual Acuity,
– Pupil Reactions,
• Extraocular Movement (III)
– Nystagmus
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•
•
•
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•
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Superior oblique (Trochlear IV)
Lateral Rectus (Abducins VI)
Trigeminal (V) sensory of face
Facial Motor (VII) blink and smile
Vestibulocochlear (VIII) hearing/balance
Glossopharyngeal (IX) swallowing
Vagus (X) larynx moves with speech
Accessory (XI) shrug shoulders
Hypoglossus (XII) move tongue
CN V
• Check sensation on the
upper, middle, and lower
part of the face.
• Check for ability to open and
close mouth in a chewing
fashion.
CN VII
• Voluntary facial movements, such as wrinkling
the brow, showing teeth, frowning, closing the
eyes tightly, pursing the lips and puffing out
the cheeks, all test the facial nerve. There
should be no noticeable asymmetry.
• CN VII also supplies taste to the anterior 1/3
of tongue.
Sensation
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Hot, Cold
Pain, Light Touch
Vibration
Proprioception
Two-point discrimination
Perform each of these tests
throughout the dermatome map.
Map of Dermatomes
Test from the sides of the neck , to the
shoulder
Circumscribe the upper and lower arms
Test down the front of the chest or back
Test the lateral sides of the thigh
Circumscribe the leg
Sensation
• Temperature sensation can be tested with a
cool piece of metal such as a tuning fork or
stethoscope diaphragm. Warms can be tested
with warm hands or warmed cloth.
• Light touch is best tested with a cotton-tipped
swab
• Pain is tested by poking gently with a sharp
object, such as a broken wooden stick from a
Q-Tip
Sensation
• Vibration
– Place a vibrating tuning fork on the fleshy portion
of the patient's toe or finger and ask him to report
when the vibration stops.
– Take care not to place the tuning fork on a bone,
since bones conduct the vibration to much more
proximal sites, where they can be detected by
nerves far from the location being tested.
Sensation
• Proprioception (joint position)
– Move one of the patient's fingers or toes up and
down and asking the patient to report which way
it moves.
– Hold the digit lightly by the sides while doing this
so that tactile inputs don't provide significant
clues to the direction of movement.
– The digit should be moved very slightly because
normal individuals can detect movements that are
barely perceptible by eye.
Sensation
• Two-point discrimination
– Use a caliper or bent paper
clip, alternating randomly
between touching the patient
with one or both points.
– Ask them each time: can you
feel one prong or two? If you
use two and they say “one”,
spread the clip points wider
and try again.
– The minimal separation (in
millimeters) at which the
patient can distinguish these
stimuli should be recorded in
each extremity.
Muscle Strength
• Upper Extremity
– Shoulder
– Elbow
– Wrist
• Lower Extremity
– Hip
– Knee
– Foot
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
Muscle Strength
• Pair the testing of each muscle group
immediately with testing of its contralateral
counterpart to enhance detection of any
asymmetries.
• Have them flex, then extend, the chosen joint.
First the right, then the left.
• Have them flex and extend that joint again, but
this time, examiner pushes against the
movement, creating resistance.
• Proceed to the next joint.