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Neurological Examination Surat Tanprawate, MD, MSc(Lond.), FRCPT Division of Neurology, Chaing Mai University Thursday,
Neurological Examination Surat Tanprawate, MD, MSc(Lond.), FRCPT Division of Neurology, Chaing Mai University Thursday,

Neurological

Examination

Surat Tanprawate, MD, MSc(Lond.), FRCPT Division of Neurology, Chaing Mai University

Thursday, December 15, 2011

Brain function
Brain function

Thursday, December 15, 2011

Brain function
Brain function

Thursday, December 15, 2011

Neurological skill

Chief complaint

History taking

Neurological examination

screening neurological examination

focused neurological examination

Consequence of the exam

Skill and method

Thursday, December 15, 2011

Aim of neurological exam

To localized the lesion

Central vs Peripheral nervous system

symmetrical vs asymmetrical

If central: cerebrum, midbrain, spinal cord

If peripheral, is it: nerve, muscle, NMJ

Thursday, December 15, 2011

Equipment

Penlight

Tongue blade

Tuning fork

Familiar objects(coin, key, paper clip)

Cotton wisp

Reflex hammer

Aromatic substances

Test tubes of hot and cold water

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Consequence of Neurologic Exam

Mental status

Consciousness: Level of consciousness, orientation

Higher cortical function

Cranial nerves

Motor system

Reflex

Sensory

Coordination

Gait and balance

Thursday, December 15, 2011

Special test

Consciousness

Higher cortical function : content of consciousness : awareness

orientation; time, place, person

higher cortical function

Mini-mental state examination

: : :
:
:
:

Ascending Reticular Activating System(ARAS) : level of consciousness : wakefulness

: stimuli and response : Glasglow Coma Score(GCS)

Thursday, December 15, 2011

Level of consciousness

Wakefulness Drowsiness

Semi-coma

Coma

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Glasglow Coma Score (GCS)

Eye response Verbal response

Motor response

Thursday, December 15, 2011

o r r e s p o n s e Thursday, December 15, 2011 First published

First published in 1974 by Graham Teasdale and Bryan J. Jennett, Professor of neurosurgery University of Glascow

Glasglow Coma Score (GCS)

E

Thursday, December 15, 2011

1. No eye opening

2. Eye opening in response to pain (Patient fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)

3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.)

4. Eyes opening spontaneously

Glasglow Coma Score (GCS)

V

1. No verbal response

2. Incomprehensible sounds. (Moaning but no words.)

3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)

4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)

5. Oriented (Patient responds coherently and appropriately to questions such as the patientʼ s name and age, where they are and why, the year, month, etc.)

Thursday, December 15, 2011

Glasglow Coma Score (GCS)

M

1. No motor response

2. Extension to pain (abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate posture)

3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate posture)

4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)

5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra- orbital pressure applied.)

6. Obeys commands. (The patient does simple things as asked.)

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Consciousness

Impairment of self awareness, person, environment, time

Clouding of consciousness

Confusional state

acute(delirium), chronic(severe dementia)

Thursday, December 15, 2011

Consciousness

Level(arousal) and content(awareness) of consciousness

Level(arousal) and content(awareness) of consciousness Arousal and awareness, the two components of consciousness

Arousal and awareness, the two components of consciousness in coma, vegetative state, minimally conscious state, and locked-in syndrome.

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Higher Cortical Function

Memory

Language

Calculation

Higher motor function(Praxis)

Higher sensory function(Gnosis)

Thursday, December 15, 2011

Memory

Short term memory

ถามคําให้ทวน 3 คํา ต้นไม้รถยนต์มือ

Long term memory

ชื่อประเทศ ชื่อพ่อแม่

Thursday, December 15, 2011

Language

Fluency: ความคล่องของการพูด

Comprehension: 1 step, 2 step, 3 step

Repetition ยายพาหลาน ไปซื้อขนมที่ตลาด

Naming: ปากกา นาฬิกา แก้วน้ํา

Reading Writing

Thursday, December 15, 2011

Aphasia

Aphasia refers to an impairment in linguistic communication produced by brain dysfunction

It must be distinguished from other disorders of verbal output such as dysarthria, mutism, and the abnormal language production of patients with thought disorder

Thursday, December 15, 2011

A:

A: Wernicke's area B: concept center M: Broca's area a--> A -auditory input to Wernicke's area

Wernicke's area

B: concept center M: Broca's area

a--> A

-auditory input to Wernicke's area

M --> m

-motor output from Broca's area

A --> M

-tract connecting Wernicke's and Broca's

areas

A --> B

-pathway essential for understanding spoken

input

B --> M

-pathway essential for meaningful verbal output.

Thursday, December 15, 2011

Conduction aphasia Articulatory disorder (aphemia)
Conduction aphasia
Articulatory
disorder
(aphemia)

transcortical motor aphasia

Transcortical sensory aphasia

Motor

aphasia

Sensory

aphasia

Pure

word

deafness

Lichtheim's diagram of the language system

Praxis

Praxis Thursday, December 15, 2011 Gnosis

Thursday, December 15, 2011

Praxis Thursday, December 15, 2011 Gnosis

Gnosis

Praxis Thursday, December 15, 2011 Gnosis

Mini-Mental

State

Examination

(MMSE)

Thursday, December 15, 2011

Mini-Mental State Examination (MMSE) Thursday, December 15, 2011

Cranial nerve

Cranial nerve Thursday, December 15, 2011

Thursday, December 15, 2011

Olfactory nerve (CN I)

Test each nose with familiar non- irritate smell

Coffee bean

Thursday, December 15, 2011

nerve (CN I) • Test each nose with familiar non- irritate smell • Coffee bean Thursday,

Optic nerve (CN II)

Visual acuity

Visual field Fundoscopy

Swinging flashlight test

Thursday, December 15, 2011

Visual acuity

Using hand held card (14 inches) or snellen wall chart, assess each eye separately

Direct patient to read aloud line with smallest lettering that they ʼ re able to see

Thursday, December 15, 2011

Direct patient to read aloud line with smallest lettering that they ʼ re able to see

Visual acuity:

Assessment

20/20 = patient can read at 20` with same accuracy as person with normal vision.

20/400 = patient can read at 20` what normal person can read from 400` (i.e. very poor acuity).

Thursday, December 15, 2011

= patient can read at 20` what normal person can read from 400` (i.e. very poor
Thursday, December 15, 2011 Visual field

Thursday, December 15, 2011

Visual field

Thursday, December 15, 2011 Visual field

Pupillary response

Direct light reflex

Consensual light reflex

Thursday, December 15, 2011

Pupillary response Direct light reflex Consensual light reflex Thursday, December 15, 2011
Thursday, December 15, 2011 Fundoscopic examination

Thursday, December 15, 2011

Fundoscopic examination

Thursday, December 15, 2011 Fundoscopic examination
Thursday, December 15, 2011 Fundoscopic examination

Cranial nerve III, IV, VI Extraocular movement

Cranial nerve III, IV, VI Extraocular movement Thursday, December 15, 2011

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Trigeminal nerve (CN V)

Facial sensation

Motor: jaw strength and muscle bulk

Corneal reflex

Thursday, December 15, 2011

V) • Facial sensation • Motor: jaw strength and muscle bulk • Corneal reflex Thursday, December

Masseter test

Masseter test Thursday, December 15, 2011

Thursday, December 15, 2011

Corneal Reflex

Corneal Reflex Thursday, December 15, 2011
Corneal Reflex Thursday, December 15, 2011

Thursday, December 15, 2011

Facial nerve (CN VII)

“Tear, Ear, Taste, Face”

Thursday, December 15, 2011

Facial nerve (CN VII) “Tear, Ear, Taste, Face” Thursday, December 15, 2011
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Rinne test

Rinne test Vestibulocochlear nerve (CN VIII) Thursday, December 15, 2011 Weber test

Vestibulocochlear nerve (CN VIII)

Thursday, December 15, 2011

Weber test

Rinne test Vestibulocochlear nerve (CN VIII) Thursday, December 15, 2011 Weber test

Vagus nerve (CN X)

Vagus nerve (CN X) A normal soft palate is illustrated on the left. On the right,

A normal soft palate is illustrated on the left. On the right, a right palatal palsy from a lower motor neuron X nerve lesion has resulted in deviation of the uvula to the left.

Thursday, December 15, 2011

X nerve lesion has resulted in deviation of the uvula to the left. Thursday, December 15,

Hypoglossus nerve (CN XII)

Motor examination

Muscle bulk

Muscle fasciculation/cramp

Muscle tone

Muscle strength

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Reflex

Reflex Thursday, December 15, 2011

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Reflex Thursday, December 15, 2011
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Thursday, December 15, 2011

Reflex

Superficial Reflexes

Plantar reflex

Stroke lateral side of foot from heel to the ball, then across to the medial side

foot from heel to the ball, then across to the medial side Thursday, December 15, 2011

Thursday, December 15, 2011

Normal response is a positive plantar reflex

Plantar flexion of all toes

Abnormal response is the Babinski sign in those 2 yoa

Dorsiflexion of the great toe with or without fanning of the other toes

Sensory function

Sensory function Thursday, December 15, 2011

Thursday, December 15, 2011

Sensory function

Primary sensory functions

Always with the person ʼ s eyes closed

Sites

Vision, hearing, smell, taste, and facial sensation

Hands

Lower arms

Abdomen

Feet

Lower legs

Thursday, December 15, 2011

Sensory function

Primary sensory functions

Superficial touch

Use a cotton wisp

Have the person point to the area touched

Superficial pain

Sharp and dull sensations

Allow 2 seconds between each stimulus

Temperature and deep pressure

ONLY USED when superficial pain sensation is not intact

Thursday, December 15, 2011

Sensory function

Primary Sensory Functions

Vibration

Place stem of tuning fork against bony prominences

Begin distally

Sites

Sternum

Finger – wrist – elbow - shoulder

Toes – ankle – shin

Position of joints (great toes, one finger on each hand)

Up

Down

Thursday, December 15, 2011

Proprioception

Proprioception

The sensation of position and muscular activity originating from within the body which provides awareness of posture, movement, and changes in equilibrium

Test

Joint position test

Romberg ʼ s test

Thursday, December 15, 2011

Sensory function

Cortical Sensory Functions

Always with the person ʼ s eyes closed

Stereognosis

Ability to identify a familiar object by touch and manipulation

Tactile agnosia: inability to recognize objects

Graphesthesia

With a blunt pen, draw a letter or number on the palm

Should be readily recognized

Thursday, December 15, 2011

Sensory function

Cortical Sensory Functions

Point location

Touch an area of the body and ask the person to point to where you have touched

This is being tested the same time as superficial touch

Extinction phenomenon

Simultaneously touch one or both sides of the body

Ask the person to point to where you have touched

Thursday, December 15, 2011

Sensory function

Cortical sensory functions

Two-point discrimination

Use two pointed objects, alternate touching skin with one or two points

Find the distance at which the person can no longer discriminate 2 point

Thursday, December 15, 2011

Finger tip

Toes

Palms

Forearms

Upper arms and thighs

2-8 mm 3-8 mm 8-12 mm 40 mm 75 mm

Cerebellar function

Coordination and fine motor skill

Rapid rhythmic alternating movement

Have seated person alternately pronate and supinate hands, patting knees, and gradually increasing speed OR

Have person touch thumb to each finger on the same hand sequentially from index to little finger and back, gradually increasing speed

person should be able to do these movements smoothly, maintaining rhythm, with increasing speed

Observe for slow, stiff, non-rhythmic, or jerky movements

Thursday, December 15, 2011

Cerebellar function

Coordination and fine motor skill

Accuracy of movement

Finger-to-finger test with person ʼ s eyes open

Movements should be rapid, smooth, and accurate

Consistent past pointing may indicate cerebellar impairment

Heel-to-shin with person supine

Should move heel from knee up and down the shin in a straight line, without irregular deviations to the side

Thursday, December 15, 2011

Finger-to-nose test.

Finger-to-nose test. A. Normal: Smooth trajectory throughout movement. B. Cerebellar hemisphere dysfunction: Tremor

A. Normal: Smooth trajectory throughout movement.

B. Cerebellar hemisphere dysfunction: Tremor increases in amplitude as finger approaches target.

C. Parkinsonian: Tremor may be present at initiation of movement, but smoothes out as finger approaches target.

D. Essential tremor: Low-amplitude fast tremor throughout trajectory, may worsen as finger approaches target.

Thursday, December 15, 2011

Cerebellar function

Stance and gait

Gait

Tamdem walk

Romberg ʼ s test

Thursday, December 15, 2011

Consequence of Neurologic Exam

Mental status

Consciousness: Level of consciousness, orientation

Higher cortical function

Cranial nerves

Motor system

Reflex

Sensory

Coordination

Gait and balance

Thursday, December 15, 2011

Special test

Surat Tanprawate, MD, MSc(Lond.), FRCP(T) CertHE(Hist Med) Neurology staff, Division of Neurology, CMU The Northern

Surat Tanprawate, MD, MSc(Lond.), FRCP(T) CertHE(Hist Med) Neurology staff, Division of Neurology, CMU The Northern Neuroscience Center, CMU

Downloadable at www.openneurons.com

Thank You for Your Kind Attention

Thursday, December 15, 2011