Neurological Assessment and Examination

Neurological Assessment and Examination



The basic aim is to answer the following:

 

Is there a neurological problem? What is the site of the lesion in the nervous system? (anatomical diagnosis) What are the pathological conditions that can cause the lesion? (pathological diagnosis) What is the most likely diagnosis?

Neurological Assessment and Examination The neurological assessment involves: I. History of illness II. Clinical examination:
1. 2. 3. 4. Handedness of the patient Physical developement and general appearance Vital signs General examination - Head and neck - Chest
- Abdomen - Lower limbs - skeletal

5. Neurological examination

Neurological Assessment and Examination

I. The Neurological History:

History involves questioning and observing the patient. Observe how the patient walks into the examining room, how he speaks, and how he climbs to examination couch.

Neurological Assessment and Examination

I. The Neurological History:

Personal data Neurological complaint Present history Past history Family history Drug history Social history

II. Neurological examination

1234Mental state Speech Cranial nerves Limbs and trunk

- Posture and deformity - Muscle state - Muscle tone - Muscle power .Superficial - Sensations
. Deep . Cortical

- Reflexes

. Superficial
. Deep . Pathological

- Coordination and gait - Sphincters

Neurological Assessment and Examination

Neurological Examination:
Mental state:
1. Conscious state
This can be assessed by using the "Glasgow Coma Scale".

2. Orientation 3. Memory 4. Emotional state 5. Presence of delusions or hallucinations

Neurological Assessment and Examination The Glasgow Coma Scale

1. Eye Opening Response
Spontaneous To verbal command To pain No response Oriented Disoriented (Confused) Inappropriate words Incomprehensible speech (sounds) No response Obeys commands Localizing to pain Flexion withdrawal in response to pain Spastic flexion (decorticate posturing) Extension in response to pain (decerebrate posturing) No response 4 points 3 points 2 points 1 point 5 points 4 points 3 points 2 points 1 point 6 points 5 points 4 points 3 points 2 points 1 point

2. Best Verbal Response

3. Best Motor Response

Neurological Assessment and Examination The Glasgow Coma Scale Categorization:

A score is applied to each category and the total summed to give an overall value ranging from 3-15. 3-

Head Injury Classification:

Severe Head Injury Moderate Head Injury Mild Head Injury GCS score of 8 or less GCS score of 9 to 12 GCS score of 13 to 15

Neurological Assessment and Examination

Neurological Examination:
Speech: There are four main speech disorders:
1. Mutism 2. dysphonia 3. Dysarthria 4. Dysphasia

Neurological Assessment and Examination

Neurological Examination:
Cranial Nerves Examination:
CN I. Olfactory nerve:
Tested by patient sniffing non irritant odors in each nostril separately.

Causes of anosmia in neurosurgery:

1. Following head injury; skull base fracture. 2. Tumors involving anterior cranial fossa.

Neurological Assessment and Examination

Cranial Nerves Examination:

CN II. Optic nerve:
1. Fundus examination:
a. b. Papilloedema Optic atrophy

2. 3. 4.

Visual acuity: by Snellen's chart Visual field: using either confrontation or perimeter (automated, or Bjerrum screen). Light reflex

Neurological Assessment and Examination Cranial Nerves Examination:

CN III, IV, VI.
1. 2. Position of the eyelids Pupils
Size, shape, equality Light and accommodation reflexes

3.

Extraocular movement

Neurological Assessment and Examination Cranial Nerves Examination:

CN V. Trigeminal nerve:
Motor: Is tested while the patient clenches their teeth; testing the power of jaw opening and lateral deviation of the jaw. Sensory: Test facial sensation over the three divisions (ophthalmic, maxillary, mandibular). Reflexes: Test corneal and Jaw jerk reflexes.

Neurological Assessment and Examination Cranial Nerves Examination:

CN VII. Facial nerve:
Motor: Facial movements (upper and lower face) - Upper motor neuron facial palsy - Lower motor neuron facial palsy Sensory: Sensation over the anterior two third of the tongue. Reflexes: Glabellar, shrimer's test.

Neurological Assessment and Examination Cranial Nerves Examination:

CN VIII. Vestibulocochlear nerve:
Vestibular part: Balance, Nystagmus, Caloric test Cochlear part: Hearing acuity, Rinne's and Weber's tests

Neurological Assessment and Examination Cranial Nerves Examination:

CN IX. Glossopharyngeal nerve:
Motor: stylopharyngeus muscle. Sensory: posterior third of the tongue. Reflexes: Gag reflex via the pharyngeal mucosa.

Neurological Assessment and Examination

Cranial Nerves Examination:

CN X. Vagus nerve:
Motor: uvula movement. Reflexes: Gag reflex.

Neurological Assessment and Examination Cranial Nerves Examination:

CN XI. Accessory nerve:
Test Trapezius and Sternomastoid muscles (contour and power).

Neurological Assessment and Examination Cranial Nerves Examination:

CN XII. Hypoglossal nerve:
Extrude the tongue and push the inner side of the cheek with it. Also detect wasting, weakness and fasciculations.It will deviate toward side of weakness.

Neurological Assessment and Examination

Neurological Examination:
Examination of the limbs and trunk:
- Posture and deformity - Muscle state - Muscle tone - Muscle power - Sensations - Reflexes - Coordination and gait - Sphincters

Neurological Assessment and Examination Examination of the limbs and trunk:

Posture and deformity
The patient's posture may indicate an underlying neurological disability. Posture due to sciatica, poliomyelitis, decerebrate posture. Deformity due to peripheral nerve injury.

Neurological Assessment and Examination Examination of the limbs and trunk:

Muscle state
- Muscle atrophy and wasting - Muscle hypertrophy - By inspection or measuring the muscle circumference.

Neurological Assessment and Examination Examination of the limbs and trunk:

Muscle tone
Tested by passive flexion extension movement of the wrist, elbow, hip, knee, and ankle joints. Decreased tone:
a. Lower motor neuron lesions. b. Cerebellar lesions.

Increased tone:
a. b. c. Clasp knife spacticity: upper motor neuron lesions. Lead pipe and Cog wheel rigidity: in extra pyramidal system affection. clonus (ankle and patellar clonus) are indicative of marked hypertonia.

Neurological Assessment and Examination Examination of the limbs and trunk:

Muscle power
- The power should be tested in all limbs, comparing each side. - The muscle power is graded from 0-5. - Compare between upper and lower motor neuron weakness.

Neurological Assessment and Examination Examination of the limbs and trunk: Sensation
1. Superficial sensation
a. pain (pinprick). b. temperature. c. light touch (crude touch). d. fine touch.

2.

Deep sensation:
a. joint position. c. pressure sense. b. joint movement. d. vibration sense.

3.

Cortical sensation:
a. tactile localization. c. stereognosis. b. two point discrimination. d. graphaesthesia

Neurological Assessment and Examination

Examination of the limbs and trunk:

Reflexes:
Superficial reflexes:
a. b. c. d. Plantar reflex Abdominal reflex Cremasteric reflex Anal reflex S1 T7T7-T12 L1 S4S4-S5

Deep reflexes:
a. b. c. d. e. Biceps jerk Triceps jerk Brachioradialis jerk Ankle jerk Knee jerk C5C5-C6 C6C6-C7 C5C5-C6 S1 L3L3-L4

Neurological Assessment and Examination Examination of the limbs and trunk: Reflexes:
Pathological reflexes:
a. b. c. Pyramidal reflexes: the Hoffman reflex (C7-C8), and Finger jerk. (C7Primitive reflexes (Grasp reflex, and Glabellar reflex). Babinski reflex

Neurological Assessment and Examination Examination of the limbs and trunk: The Reflexes:
Reduced tendon reflexes:
It occurs in cases of lower motor neuron lesions.

Increased tendon reflexes:

It occurs in cases of pyramidal lesions (upper motor neuron lesions).

Neurological Assessment and Examination Examination of the limbs and trunk: Coordination:
upper limbs: - finger- nose test finger- finger- finger test finger- diadochokinesia lower limbs: - heel- shin test heel- diadochokinesia

Neurological Assessment and Examination

Examination of the limbs and trunk:

Coordination:
Romberg's test Tandem gait Defect in coordination can be caused by: - Cerebellar disorders (cerebellar ataxia). - Posterior column lesions (sensory ataxia). - Muscular weakness.

Neurological Assessment and Examination Examination of the limbs and trunk: Gait:
Circumduction gait High stepping gait Shuffling gait Ataxic gait Waddling gait Spastic gait Stamping gait

Neurological Assessment and Examination

Neurological Examination:
Skeletal Examination: 1. Cranium: size, measurements (important in
hydrocephalus), and deformity.

2. Spine: bulge or fracture.

Neurological Assessment and Examination

Brain death:
1. 2. 3. 4. 5. 6. Lack of pupil response to light. Lack of corneal reflex to stimulation. Lack of occulocephalic reflex. Failure of vestibulo-occular reflex (Caloric test). vestibuloFailure of Gag or cough reflex on bronchial stimulation. No motor response in face or muscles supplied by the cranial nerves in response to painful stimuli. 7. Failure of respiratory movement when the patient is disconnected from the ventilator and the PaCO2 is allowed to rise to 50 mmHg. 8. Hypothermia. 9. Flat EEG. 10. Low constant intracranial pressure (ICP).

Data show design & preparation by : Dr. El-Sayed Amr - (012) 3106023