Transcript aocpmr.org

NEUROMUSCULAR EXAM
OVERVIEW
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Mini-Mental Status Exam (MMSE)
CN I-XII
Reflexes
Tone
Strength
Sensory (Pinprick and Cotton Wisp)
Proprioception and Vibration
• Romberg
• Gait
MMSE
• Orientation
 Person: What is your name?
 Place: Where are you?
 Time: What is today’s date?
CRANIAL NERVES
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I- Olfactory (Special Sensory)
II- Optic (Special Sensory)
III- Oculomotor (Motor, Parasympathetics)
IV- Trochlear (Motor)
V- Trigeminal
 Ophthalmic (Sensory)
 Maxillary (Sensory)
 Mandibular (Sensory, Motor)
VI- Abducens (Motor)
VII- Facial (Motor, Special Sensory, Parasympathetics)
VIII- Vestibulocochlear (Sensory, Special Sensory)
IX- Glossopharyngeal (Sensory, Special Sensory, Motor)
X- Vagus (Sensory, Special Sensory, Motor, Parasympathetics)
XI- Accessory (Motor)
XII- Hypoglossal (Motor)
http://www.brianjogrady.com/neurosurgery.ht
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CNI-OLFACTORY
• Sense of Smell
 Test using common scent (coffee grounds)
 Eyes closed
 One nostril at a time
CNII- OPTIC
• Visual Acuity
• Visual Fields
• Pupillary Reflex
 Direct
 Consensual
http://medicaldictionary.thefreedictionary.com/paradoxical+pupillary+reflex
CNIII- OCULOMOTOR
• Motor (External Ocular Movements)
 Superior Rectus, Medial Rectus, Inferior Rectus, Inferior Oblique
 CNIII Palsy eyes look down and out
 Ask and test for double vision
• Parasympathetics
 Accommodation (near sight)
 Constriction
 Pupillary Reflex
 Direct
 Consensual
Picture: Medial Rectus
http://www.postoconnorkadrmas.com/common-eye-problems/strabismus-eyePalsy
turn.html
EXTRAOCULAR EYE MOVEMENTS
http://clinicalexamskills.blogspot.com/2010/10/cranial-nerves-iii-iv-andvi.html
CNIV- TROCHLEAR
• Motor (Superior Oblique)
 Moves eyes down and in
 Trochlear palsy
 Trouble walking down stairs (unable to look down)
 Patient may have compensatory head tilt toward affected eye
CNV- TRIGEMINAL
• Ophthalmic
 Sensory (Bridge of nose to vertex of skull)
• Maxillary
 Sensory (Above the mouth to beneath the eyes)
• Mandibular
 Sensory (Beneath the mouth along the mandible)
 Motor
 (Muscles of mastication, tensor tympani, tensor veli palatini, myelohyoid, anterior
belly of digastric)
• Test sharp/ dull separately in all three divisions carefully
comparing bilaterally
CNVI- ABDUCENS
• Lateral Rectus
 Moves eyes out
 Most commonly affected EOM
 Ask about and test for double vision
 Double vision worse when look toward deficit (laterally)
http://meded.ucsd.edu/clinic
almed/eyes.htm
 Palsy seen with: increased intraocular pressure
(pseudotumor cerebri), diabetic neuropathy
CNVII- FACIAL
• Motor
 Muscles of facial expression
 Wrinkle forehead (bilateral innervation)
 Deficit suggests LMN injury
 Smile (contralateral innervation)
 Either UMN or LMN injury
 Look for facial droop and asymmetry
• Special Sensory
 Chordae tympani
 Sense of taste anterior 2/3 of tongue
• Parasympathetics
 Submandibular, submental, lacrimal, and all minor
salivary glands
CNVIII-VESTIBULOCOCHLEAR
• Sensory
 Vestibular (balance)
• Special Sensory
 Audition
 Rinne
 Place 512Hz tuning fork on mastoid process
 Move in front of EAM once patient can no long hear on mastoid
 Normal: Air conduction>Bone conduction
 Ossicles amplify sound
 If: Bone conduction> Air conduction→ Conductive hearing loss
 Weber
 Place 512Hz tuning fork at skull vertex
 Ask where sound is coming from
 Normal: Same both ears
http://www.google.com/imgres?q=weber+rinne+test&um=1&hl=en&safe=off&sa=N&biw=1144&bih=678&tbm=isch&tbnid=E49qzh8Qq2_MPM:&imgrefurl=http://www.netteri
mages.com/image/6928.htm&docid=zg8q_5VgYXAR4M&imgurl=http://www.netterimages.com/images/vpv/000/000/006/69280550x0475.jpg&w=475&h=550&ei=0vdQT6jhO5SEtgeCuOG6DQ&zoom=1
CNIX- GLOSSOPHARYNGEAL
• Sensory- oropharynx
 Gag Reflex
 Afferent: Glossopharyngeal
 Efferent: Vagus (Pharyngeal constrictors)
• Special Sensory
 Taste: Posterior 1/3 tongue
• Motor
 Stylopharyngeous
CNX- VAGUS
• Sensory
 Laryngopharynx
 External ear
• Special Sensory
 Taste: Epiglottis
• Motor
http://meded.ucsd.edu/clinicalmed/head.ht
 Muscles of soft palate, pharynx, and larynx
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 Efferent of gag reflex
 Test by looking for symmetric elevation of uvula “ahhh”
• Parasympathetics
 Thoracic and abdominal viscera until splenic flexure
CNXI- ACCESSORY
• Motor
 Trapezius
 Test with shoulder shrug
 Compare strength bilaterally
 Sternocleidomastoid
 Test with turning head against hand
 Turns head to contralateral side
 Compare strength bilaterally
http://theartofads.blogspot.com/2010/01/lie-to-me109.html
CNXII- HYPOGLOSSAL
• Motor
 Movements of the tongue
 Genioglossus
 Protrudes tongue
 Test by having patient stick tongue out
 Tongue deviates towards deficit
 Hypoglossus
 Myeloglossus
 Palatoglossus
http://www.johnnysilva.com/physicalexamination/right-eardrum-1.html
CN REFLEXES
• Pupillary
 Afferent: Optic
 Efferent: Oculomotor
 Remember: “In on 2, out on 3”
• Accomodation
 Afferent: Optic
 Efferent: Oculomotor
• Gag
 Afferent: Glossopharyngeal
 Efferent: Vagus
• Cough
 Afferent: Vagus
 Efferent: Vagus
REFLEXES
• Grade
 0: Absent
 1: Hyporreflexic (Illicited with distraction)
 2: Normal
 3: Hyperreflexic (Spreading of reflexes)
 4: Clonus
• Test
 Biceps (C5, C6)
 Brachioradialis (C6)
 Triceps (C7)
 Patellar (L4, L5)
 Achilles (S1, S2)
TONE
• Passive motion of extremities
 Test Both upper and lower extremities
 Spasticity: UMN Injury
 Flaccid: LMN Injury or spinal shock
STRENGTH
• Corticospinal Tract (Pyramidal Tract)
 Decussation at junction of medulla and spinal cord
• Grade
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5: Full Strength
4: Decreased compared to contralateral side
3: Movement against gravity only
2: Movement within a plane only
1: Flicker
0: Absent
• Compare bilaterally
• Differentiate decreased strength vs. Giveway
 True neuromuscular deficiency
 Testing limited by pain or malingering
SENSORY EXAM
• Pain/ Temperature
 Anterolateral Spinal Tract
 Ascends Contralaterally in spinal cord
 →Test with Pinprick and Cold (Tuning Fork)
• Dull/ Vibration
 Dorsalcolumn Medial Lemniscus
 Ascends Ipsilaterally in spinal cord
 →Test with cotton whisp/ 128Hz Tuning Fork
PROPRIOCEPTION
• Have patient close eyes
 Move distal phalynx of great toe up or down
• Romberg Test
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Patient stands with feet together
Raises hands outstretched in front
Closes eyes
Test for at least 30 sec
*Be positioned to catch patient
Positive Romberg = loss of balance on exam
http://www.jaoa.org/content/111/6/382.abstrac
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GAIT
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Patient walks across room
Returns walking on toes
Walks back on heels
Returns with tandem walk (heel-to-toe)