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
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
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
t
GAIT
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Patient walks across room
Returns walking on toes
Walks back on heels
Returns with tandem walk (heel-to-toe)