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Chapter 23

Neurologic System

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 23
Neurologic System

 Structure and Function


 Subjective Data—Health History Questions
 Objective Data—The Physical Exam
 Abnormal Findings

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-1
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 23
Neurologic System

Structure and Function


Central Nervous System (CNS)
 Cerebral cortex  Hypothalamus
– Frontal lobe
 Cerebellum
– Parietal lobe
– Occipital lobe  Brainstem
– Wernicke’s area – Midbrain
– Broca’s area – Pons
 Basal ganglia – Medulla

 Thalamus  Spinal cord

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-2
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 23
Neurologic System

Structure and Function, cont.

Pathways of the CNS


 Crossed representation
 Sensory pathways
– Spinothalamic tract
– Posterior (dorsal) column
 Motor pathways
– Corticospinal or pyramidal tract
– Extrapyramidal tracts
– Cerebellar system
 Upper motor neurons
 Lower motor neurons

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-3
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 23
Neurologic System

Structure and Function, cont.

Peripheral Nervous System


 Cranial nerves
 Spinal nerves
 Autonomic nervous system
 Reflex arc

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-4
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 23
Neurologic System

Subjective Data—
Health History Questions
 Headache  Incoordination
 Head injury  Numbness or tingling
 Dizziness/vertigo  Difficulty swallowing
 Seizures  Difficulty speaking
 Tremors  Significant past history
 Weakness  Environmental/
occupational hazards

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-5
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 23
Neurologic System

Objective Data—
The Physical Exam
 Preparation
– Screening neurologic examination
– Complete neurologic examination
– Neurologic recheck
 Equipment needed
– Penlight
– Tongue blade
– Cotton swab
– Cotton ball
– Tuning fork (128 Hz or 256 Hz)
– Percussion hammer
– Occasionally need: familiar aromatic substance
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-6
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 23
Neurologic System

Objective Data—
The Physical Exam, cont.
Test Cranial Nerves
 I—Olfactory  VII—Facial
– Motor function
 II—Optic
– Sensory function
 III—Oculomotor,
IV—Trochlear,  VIII—Acoustic
VI—Abducens (vestibulocochlear)
 V—Trigeminal  IX—Glossopharyngeal,
X—Vagus
– Motor function
– Motor function
– Sensory function
– Sensory function
– Corneal reflex
 XI—Spinal accessory
 XII—Hypoglossal
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-7
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 23
Neurologic System

Objective Data—
The Physical Exam, cont.

Motor System—Inspect and Palpate


 Muscles  Cerebellar function
– Size – Balance tests
• Gait
– Strength
• Tandem walking
– Tone • Romberg test
– Involuntary movements • Shallow knee bend
– Coordination and skilled movements
• Rapid alternating movements (RAM)
• Finger-to-finger test
• Finger-to-nose test
• Heel-to-shin test
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-8
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 23
Neurologic System

Objective Data—
The Physical Exam, cont.
Sensory System
 Person is alert,  Posterior column tract
cooperative, and – Vibration
comfortable – Position (kinesthesia)
 Guidelines for sensory – Tactile discrimination
testing (fine touch)
• Stereognosis
 Spinothalamic tract • Graphesthesia
– Pain • Two-point discrimination
– Temperature • Extinction
– Light touch • Point location

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-9
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•Stereognosis
Graphesthesia

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


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Chapter 23
Neurologic System

Objective Data—
The Physical Exam, cont.
 Test the stretch or deep tendon  Test the superficial reflexes
reflexes (DTRs) – Abdominal reflex
– Technique – Cremasteric reflex
– Grading – Plantar reflex

– Reinforcement
– Biceps reflex
– Triceps reflex
– Brachioradialis reflex
– Quadriceps reflex
– Achilles reflex (“ankle jerk”)
• Clonus

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-10
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–Biceps reflex

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


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Triceps reflex

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


Copyright © 2003, Elsevier Science (USA). All rights reserved.
Brachioradialis reflex

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


Copyright © 2003, Elsevier Science (USA). All rights reserved.
Let the Lower Legs Dangle Freely to Flex the Knee and
Stretch the Tendons. Strike the Tendon Directly Just
Below the Patella.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


Copyright © 2003, Elsevier Science (USA). All rights reserved.
Achilles reflex (“ankle jerk”)

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


Copyright © 2003, Elsevier Science (USA). All rights reserved.
Test the reflexes
 Copare right and left
 The response should be equal
 4+ Very brisk, hyperactive with clonus (short jerking
contraction of the same muscle), indicative of disease
 3+ Brisker than average, may indicate disease
 2+ average, normal
 1+ diminished, low normal
 0 no response

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 23
Neurologic System

Objective Data—
The Physical Exam, cont.
 Neurologic recheck
 Level of consciousness
– Person
– Place
– Time
 Motor function
 Pupillary response
 Vital signs
Glasgow coma scale (GCS)
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-11
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Fully alert- 15, a score of 7 or less reflects coma. (Kozier p. 703-704)
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.
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Decorticate Rigidity (abnormal flexion)

Decerebrate Rigidity (abnormal rigidity)

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


Copyright © 2003, Elsevier Science (USA). All rights reserved.
Abnormal Findings
Abnormalities in Muscle Movement
Paralysis
• Loss or impairment of the ability to
move a body part, usually as a result
of damage to its nerve supply.
• Loss of sensation over a region of the
body.
Hemiplegia
• paralysis of one side of the body
Paraplegia
• paralysis of both lower limbs due
to spinal disease or injury
Quadriplegia
• paralysis of all four limbs or of
the entire body below the neck
Paresis
• Elsevier
partial motor paralysis
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.
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Fasciculations
Rapid, continuous
twitching of resting
muscle

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


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Tic
Repetitive twiching of
a muscle group

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


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Myoclonus
Rapid, sudden jerk at a
fairly regular intervals

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


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Tremor
Involuntary
contraction of
opposing muscle
groups
•Rest tremor
•Intention tremor

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chorea
Sudden, rapid, jerky,
purposeless movement
involving limbs, trunk, or
face

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


Copyright © 2003, Elsevier Science (USA). All rights reserved.
Athetosis

Slow, twisting,
writhing,
contiuous
movement,
resembling a
snake or worm

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.


Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 23
Neurologic System

Abnormal Findings
Abnormal Gaits

 Spastic hemiparesis
 Cerebellar ataxia
 Parkinsonian (festinating)
 Scissors
 Steppage or footdrop
 Waddling
 Short leg

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-13
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 23
Neurologic System

Abnormal Findings
Common Patterns
of Sensory Loss

 Peripheral neuropathy
 Individual nerves or roots
 Spinal cord hemisection (Brown-Séquard syndrome)
 Complete transection of spinal cord
 Thalamus
 Cortex

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-14
Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 23
Neurologic System

Abnormal Findings
Abnormal Postures

 Decorticate rigidity
 Decerebrate rigidity
 Flaccid quadriplegia
 Opisthotonos

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 23-15
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